Recurring concern

Unreliable recording of required observations in care and custody

First to latest report 23 Oct 2013 — 19 May 2026

Reports that mention this concern
83
Times this concern has been raised
90
Stated actions linked to this concern
181

What this concern includes

Includes failures in recording required patient or prisoner observations, including inaccurate, delayed, anticipatory, incomplete or falsified entries, where records do not reliably reflect the observations performed. Includes paper, electronic and ACCT-related observation records across care and custody settings.

What is not included
  • Excludes failures to perform or maintain the required observation itself where the recording process is not deficient.
  • Excludes unclear observation requirements, observation-level decisions and generic observation assurance or auditing where inaccurate or delayed recording is not the shared unsafe condition.
  • Excludes general clinical, care or custody record-keeping deficiencies unrelated to required observations.
  • Excludes recording of non-observation activities, such as searches, movements, inspections or clinical decisions, unless the assertion specifically concerns a required observation record.

Reports and published responses 83 reports

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

  1. Coventry

    AI-generated summary

    John James Leo Scallan · 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 James Leo Scallan was admitted to hospital after sustaining injuries in an alleged assault and was subsequently transferred to a mental health ward as an informal patient. He was found unresponsive following a cardiac arrest, and the levels of sedative drugs in his blood after death exceeded those prescribed. Concerns were raised about the adequacy and reliability of intermittent observations, including staff understanding of the observation policy and reluctance to enter a patient's room to conduct checks.

    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 observation sheets in line with policy

    Wider context from the report

    “1. 1. The adequacy and reliability of the intermittent observations. 2. 2. The Observation and Engagement Policy indicates checks should be seen in terms of positive engagement with the patient and involve, whenever possible, interaction and positive contact with the patient and sighting the patient from a distance and recording whereabouts is not acceptable intermittent observation. The evidence from the front-line health care assistants showed little insight into the requirements of intermittent observations as well as awareness of the new observation sheets and how these should be completed in line with the policy. There was a clear reluctance by members of staff to enter a patient’s room to conduct observations in particular, when the patient was sleeping in the middle of the day. ”

    Source location

    John James Leo Scallan · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  2. South Wales Central

    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

    Failure to record 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

    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 October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.

    Verbatim wording from the response

    “• For the month of October 2017 documentation to be reviewed (audit) on all patients who have sustained a fall on AMU which will include compliance with neurological observations”

    Source location

    2017-0315-Response-by-University-Health-Board
    Page 2 · response
    Published 28 November 2017

    Open published response

  3. London (City)

    AI-generated summary

    SARAH LYNNE REED · 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

    Sarah Lynne Reed took her own life on 11 January 2016 in a single-occupancy cell at HMP Holloway, using a ligature made from bed linen. The report identifies concerns about delays in obtaining fitness-to-plead reports, management of her medication and deteriorating mental health, inappropriate reduction of observations, delays and deficiencies in care planning, and cancelled visits that contributed to her isolation.

    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 record prisoner observations immediately or as soon as practicable

    Wider context from the report

    “(11) In addition the Coroner observes that HMP Holloway maintained a practice of recording observations on prisoners which deviated from the national instruction. According to the national policy Management of prisoners at risk of harm to self, to others and from others (Safer Custody) (PSI 64/2011) observations should be recorded ‘immediately or as soon as practicable thereafter’. According to the local policy at HMP Holloway, as implemented in this case, any observations at any time need be recorded only at four hour intervals in summary form. ”

    Source location

    SARAH LYNNE REED · 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

    Issue learning bulletins reinforcing multidisciplinary ACCT reviews, required timescales, written contributions and prompt recording of observations.

    Verbatim wording from the response

    “delaying simply to allow a specific person to attend or contribute, it makes clear that there must be continuity of membership of the ACCT multidisciplinary team. The basis for this is that team members can make a meaningful contribution only if they are fully briefed and familiar with the prisoner’s situation. In order to reinforce this message, a learning bulletin (ACCT - Case Reviews, CAREMAPS and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner’s management cannot attend the review, they must submit written contributions.”

    Source location

    2017-0208-Response-by-NOMS
    Page 3 · response
    Published 1 August 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

    National policy already requires immediate recording of observations and does not permit prisons to adopt conflicting local policies.

    Verbatim wording from the response

    “You ask whether it is acceptable that a prison should be permitted to develop a local policy which is at variance with national policy. I can confirm that it is not. As you rightly state, under national policy, observations should be recorded immediately, or as soon as possible thereafter. I can confirm that this was reiterated in a learning bulletin (ACCT - Conversations and Observations) published in July this year, to which you refer in your report.”

    Source location

    2017-0208-Response-by-NOMS
    Page 3 · response
    Published 1 August 2017

    Open published response

  4. Manchester City

    AI-generated summary

    Name not published · 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

    A 79-year-old woman was admitted to hospital on 15 March 2015 with hypothermia, reduced responsiveness and reduced mobility. She developed pneumonia, sepsis and acute respiratory distress syndrome, and died on 23 March 2015. The principal concerns were failures in investigations and handover, mental-capacity assessment, monitoring and escalation of deterioration, and staffing competence and seniority.

    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 and calculate neurological or general observations

    Wider context from the report

    “5. Ensuring that all neurological and/or general observations are appropriately undertaken, accurately recorded and calculated but also escalated as necessary. It is a fundamental part of basic medical and nursing care that a patient who requires neurological or general observations has them completed in a timely manner, accurately recorded and calculated and then appropriately escalated. This was simply not done and simple systems or protocols could be introduced to ensure that this is completed. It would seem that the primary responsibility for this should be shared between the Nurse in charge of the individual patient and the nurse in charge of the AMU. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  5. Coventry

    AI-generated summary

    Joleen Linton · 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

    Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant 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

    Inaccurate recording of patients' positions in bed on observation charts

    Wider context from the report

    “(3) The recording of the patient's position in bed was not accurately recorded on the observation chart. At least one entry was, having regard to the evidence, obviously erroneous; ”

    Source location

    Joleen Linton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. East London

    AI-generated summary

    Mrs Anna Teresa Walker · 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 Anna Teresa Walker underwent a liver biopsy on 8 July 2016 and suffered a bleed caused by a tear to the hepatic artery. She died in hospital the following morning after a significant delay in detecting the bleed. The principal concerns were that required post-operative checks were not carried out, monitoring responsibilities were unclear, and the appropriate environment for post-operative monitoring was not provided.

    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 document post-operative checks

    Wider context from the report

    “1. The Consultant Radiologist who performed the procedure confirmed that the post-operative checks were not compliant with the Trust’s Protocol. Only 2 complete checks were carried out (at 10:45 and 11 am). The check at 11:50 was not complete. There were no further post-operative checks documented on the observation sheet after 11:50, despite the concerning observations at that time. The Consultant Radiologist gave evidence that had the appropriate post-operative checks been carried out, the bleed was likely to have been detected at an earlier stage. He further confirmed that had the bleed been detected at an earlier stage Mrs Walker’s death is likely to have been avoided on the 9th July 2016. ”

    Source location

    Mrs Anna Teresa Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Buckinghamshire

    AI-generated summary

    JACK OLIVER PORTLAND · 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

    Jack Oliver Portland was a prisoner who was diagnosed with substance-induced psychosis and later detained under the Mental Health Act. He died on 27 December 2015 at Wycombe Hospital while on unescorted leave from the Whiteleaf Centre; the medical cause of death was morphine and ethanol toxicity. Concerns included the management and communication of ACCT documents, family communication, discharge planning for a vulnerable and homeless prisoner, and the coordination of coronial disclosure.

    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 leave observation charts contemporaneously and consistently

    Wider context from the report

    “(3) The manually-completed observation charts, forming the third element of an effective leave management process, were acknowledged to be filled out sometimes retrospectively, sometimes prospectively, sometimes by reference to the whiteboard (and evidence suggested amended later) rather than always being completed in the ward round. There was scope for human error and discrepancies between the various records of leave. ”

    Source location

    JACK OLIVER PORTLAND · 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

    Require hourly physical handover of observation charts, with both allocated staff checking that records are complete and accurate.

    Verbatim wording from the response

    “The new SOP referred to above is being tested on Sapphire ward. It clarifies and simplifies the management of leave on the ward. It gives clear instruction as to how leave is granted, the nursing level assessment, and simplifies the recording of leave on one collective ward document (appendix 2).”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 2 · response
    Published 5 March 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

    Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.

    Verbatim wording from the response

    “Staff have been strongly reminded that it is not appropriate to fill in observations paperwork prospectively or retrospectively. This is now monitored by the Matron. We are in the process of reviewing the Trust’s Observation Policy, and will ensure that this is also made very explicit within the new version. This policy review will be complete by the end of April 2017.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 2 · response
    Published 5 March 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

    Require shift coordinators to sign off relevant observation and leave-record sheets before handover.

    Verbatim wording from the response

    “An existing SOP which covers shift co-ordination has had a new action added, which is that the shift co-ordinator signs off all relevant sheets, including observation charts, to ensure that all staff have fully completed the required paperwork, including the leave record form, and it is in order before handing over to the next shift.”

    Source location

    2017-0049-Response-by-Oxford-Health-NHS-Trust
    Page 3 · response
    Published 5 March 2017

    Open published response

  8. Milton Keynes

    AI-generated summary

    Anthony Thomas McManus · 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

    Anthony Thomas McManus, who was detained under Section 37 of the Mental Health Act and resident at Chadwick Lodge, was found hanging from a bathroom door using a draw string bag after he was not visible during overnight checks on 8 December 2015. Concerns were raised about the unit’s observation system, including observations being conducted at fixed times, some not being carried out, and charts being completed retrospectively.

    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 record observations contemporaneously

    Wider context from the report

    “(1) The system of observations carried out within the unit, particularly at night is in need of reform. (2) Many of the nurses were conducting hourly observations every hour at the same time each hour, rather than randomly. (3) Some observations were not carried out and the observation chart completed at the end of the shift. ”

    Source location

    Anthony Thomas McManus · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Brighton and Hove

    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

    Potential inaccurate timing of recorded observations

    Wider context from the report

    “(5) It was also suggested to me that the observations taken at 11 o’clock, 11.05, 11.10 and 11.15 were not in fact taken at those times but were taken later, after the first relatively short lived loss of consciousness which occurred at around 11.15. If this is correct then this is really an extremely worrying use of this assessment tool. ”

    Source location

    Diana Maxine RITCHIE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Leicester City and South Leicestershire

    AI-generated summary

    Michael Williams · 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 Williams died by hanging in his locked prison cell on 15 September 2015 while subject to four observations per hour and after he had threatened to take his life, appeared tearful and anxious, and blocked the observation panel. The concerns included missed and predictable observations, the lack of an explanation for missed checks, and an approximately one-hour delay before the cell was opened after he became unobserved.

    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

    Predictable timing of documented observations

    Wider context from the report

    “Mr Williams should have been observed 4x every hour during the evening of 15th September 2015. Several of these checks were missed, and after he blocked the observation panel, he could only be heard, not seen. a) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour, and were therefore predictable. This is not best practice and should be discouraged. b) There was no explanation for the missed observations. c) Mr Williams was unobserved for approximately 1 hour before the cell door was opened, and he was found deceased. The jury found this was inappropriate delay and I agree with them. Clear guidance and training should be provided, and regularly repeated, to assist the Prison Officers in managing such situations in a timely way. ”

    Source location

    Michael Williams · 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

    Implement unpredictable ACCT observations, remind staff of requirements, and monitor compliance through management checks and document quality assurance.

    Verbatim wording from the response

    “(1) Observations (where they were carried out) were documented at precise 15 minute intervals, commencing on the hour and therefore predictable. This is not best practice and should be discouraged. Prison Service Instruction 64/2011 Safer Custody sets out very clearly the requirement for observations to be conducted at unpredictable times, for example four times an hour, as opposed to every 15 minutes. All relevant staff at HMP Leicester have been reminded of this, and management checks are now in place to ensure that staff are correctly undertaking observations. All ACCT documents are quality assured and monitored by the Head of Safer Custody.”

    Source location

    2016-0245-Response-by-NOMS
    Page 1 · response
    Published 11 July 2016

    Open published response

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

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Data last updated 7 September 2026