Recurring concern

Inadequate staff competence to recognise and respond to acutely unwell patients

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First reported 10 Jan 2014•Latest report 7 Apr 2025

Definition

What this concern includes

Includes failures of staff training, competence assurance, guidance embedding or ongoing preparation specifically intended to enable staff to recognise and respond to acutely unwell patients or residents, as well as reported staff capability failures that directly impair recognition, escalation or initial treatment of acute illness.

Not included

Excludes generic staff training, resourcing or competence deficiencies without a direct connection to recognising or responding to acutely unwell patients.
Excludes failures of a separately named early-warning, triage, emergency-response or condition-specific system where that system provides the more specific supported boundary.
Excludes failures occurring after acute illness has been reliably recognised and escalated, including definitive treatment or specialist-care shortcomings.
Excludes general clinical deterioration concerns where no staff competence, preparation or acute-illness recognition-and-response deficiency is identified.

Reports: 6
Individual concerns: 7
Date range: 2014–2025
Stated actions: 3

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.

Care Quality Commission2

Nursing and Midwifery Council2

Anson Court Residential Home1

Cwm Taf Morgannwg University Local Health Board1

Department for Digital, Culture, Media and Sport1

Department of Health and Social Care1

Faculty of Intensive Care Medicine1

General Medical Council1

Isle of Wight NHS Trust1

Liverpool University Hospitals NHS Foundation Trust1

NHS Central East Integrated Care Board1

NHS Cheshire and Merseyside Integrated Care Board1

NHS England1

Northamptonshire Safeguarding Children Partnership1

North West Anglia NHS Foundation Trust1

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.

7 Apr2025
Cambridgeshire and Peterborough
Concerns raised1
1. Failure to embed HSSIB critically unwell patient guidance in staff training
This report raised 21 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

Christian James Gabriel Hobbs · 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

Christian James Gabriel Hobbs, a 17-year-old, suffered an acute deterioration at home and was taken to hospital on 26 December 2017, where he developed cardiac arrest and died after treatment was stopped. The inquest recorded multi-organ failure, cardiogenic shock and arrhythmogenic cardiomyopathy. Concerns included the absence of an echocardiogram before his arrest, non-targeted fluid management, delays in obtaining blood gases, team communication, radiology documentation, differential diagnosis, ECG interpretation, record keeping and emergency-department alarm data retention.

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 embed HSSIB critically unwell patient guidance in staff training
Wider context from the report
“POINT O – LEARNING FROM HSSIB REPORTS I have a concern on whether the HSSIB report – RECOGNISING AND RESPONDING TO CRITICALLY UNWELL PATIENTS is firmly embedded in staff training. ”
Source location
Christian James Gabriel Hobbs · Prevention of Future Deaths report
Page 21 · concerns
Open source report
28 May2024
South Wales Central
Concerns raised1
1. Failure to fully roll out required staff training
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Standardise the Acutely Unwell Course on ESR and increase monthly capacity to 25–30 training places from September 2024.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated planned
2. Action
  Promote the Acutely Unwell Course through posters and staff email and encourage ward managers and senior nurses to book staff.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
3. Action
  Use the full outreach staffing complement to run monthly training and complete Acutely Unwell Course attendance for surgical-ward staff by the end of 2024.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated planned
AI-generated summary

Clara Novella Winter · 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

Clara Novella Winter underwent elective laparoscopic cholecystectomy and subsequently developed an incarcerated ischaemic bowel with perforation, requiring emergency surgery. She died on 19 November 2022 after being unable to recover. Concerns were raised about post-operative care, including the timeliness of escalation and maintenance of fluid balance charts; related staff training had not been fully rolled out because of resourcing issues.

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 fully roll out required staff training
Wider context from the report
“1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023. 2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory. ”
Source location
Clara Novella Winter · 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
Standardise the Acutely Unwell Course on ESR and increase monthly capacity to 25–30 training places from September 2024.

Verbatim wording from the response
“From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 31 May 2024
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
Promote the Acutely Unwell Course through posters and staff email and encourage ward managers and senior nurses to book staff.

Verbatim wording from the response
“From September 2024 the Acutely Unwell Course will be a CTM UHB standardised course available on ESR (Electronic Staff Record) for staff to book and have a larger capacity of training numbers of 25-30 spaces per month. The course is promoted via posters and staff email and all ward managers and senior nurses are encouraged to book staff members onto the course.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 31 May 2024
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
Use the full outreach staffing complement to run monthly training and complete Acutely Unwell Course attendance for surgical-ward staff by the end of 2024.

Verbatim wording from the response
“The Acutely Unwell Patient study day is facilitated by the outreach teams within Cwm Taf Morgannwg UHB. The course runs monthly within Prince Charles, Royal Glamorgan and Princess of Wales hospitals. Registered nurses are booked on by the ward manager. It is a one-off, non-mandatory course but it is advisable that staff complete at least every 3 years.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 31 May 2024
Open published response
16 Sep2021
Black Country
Concerns raised1
1. Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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

Mrs Tripta Bhanote · 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 Tripta Bhanote, who was 86 and living in a residential care home, was found on the floor on several occasions in May 2020 and her condition then declined rapidly before she died. Concerns included unclear procedures for escalating acute illness to emergency services, uncertainty about referral to the enhanced care and quality team, and poor procedures for identifying residents’ DNAR status.

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 clarity among care staff about escalation requirements for acutely unwell patients or residents
Wider context from the report
“1. Evidence emerged during the inquest that there was a lack of clarity and understanding by care staff in the requirements for escalation to emergency services when a patient/resident becomes acutely unwell. ”
Source location
Mrs Tripta Bhanote · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Oct2018
Liverpool and the Wirral
Concerns raised1
1. Insufficient clinical staff training in identifying and treating sepsis
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

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
Insufficient clinical staff training in identifying and treating sepsis
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
24 Nov2017
Southampton and New Forest
Concerns raised1
1. Poor SANNP and ANNP training in recognition of respiratory distress and PPHN
This report raised 10 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

Owen Richard Widlake · 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

Owen Widlake was born full term and healthy but aspirated meconium and developed worsening respiratory failure. He died at Southampton General Hospital on 31 May 2016 after late diagnosis of persistent pulmonary hypertension of the newborn and an acute intraventricular haemorrhage. Concerns included staffing and medical cover, recognition and escalation of respiratory distress, observation records, staff training, transfer arrangements, and handovers.

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
Poor SANNP and ANNP training in recognition of respiratory distress and PPHN
Wider context from the report
“(1a) Staffing levels over the weekend and bank holiday, in particular the use of ANNP and SANNP trained staff to replace junior and registrar level doctors on duty covering NICU. (1b) The need for a dedicated junior level doctor or registrar to be on duty 24 hours covering NICU, and not a limited 3 / 4 hour shift. (1c) The need to clarify as to the role an ANNP or SANNP has, whether in a nursing capacity or medical capacity, and how they are perceived by other staff. 2) The observations for children in transition or admitted to NICU are not recorded seamlessly nor are easily viewable whether on a chart or graph. 3) The nursing staff do not appear able to escalate concerns either i) due to lack of clear care plans and escalation markers ii) poor training particularly the SANNP and ANNP in the recognition of respiratory distress and PPHN ii) a lack of empowerment indicating a lack of leadership. 4) The on going training undertaken of nursing staff in relation to PPHN and respiratory distress has been the responsibility of SANNP ████████ and a consultant, with no indication that they have undertaken training themselves. 5) Concern as to staff deciding whether a child in respiratory distress should be NBM or not and what is the guidance on this. 6) The Transfer policy for this Trust and what would be guidance or indicators as to the seeking of tertiary level assistance and transfer, especially when a crisis point may be reached past 10pm. 7) What is the current system in place for handovers between medical staff and nursing staff, whether written or verbal, and what information must be included as part of that handover. ”
Source location
Owen Richard Widlake · Prevention of Future Deaths report
Page 1 · concerns
Open source report
10 Jan2014
Coventry
Concerns raised2
1. Failure of nursing home staff to recognise acutely unwell residents
2. Lack of ongoing training in recognition and treatment of acutely unwell residents
This report raised 7 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

Mary WALDRON · 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

Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.

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 nursing home staff to recognise acutely unwell residents
Wider context from the report
“(1) failure of the nursing home staff to recognise an acutely unwell resident; ”
Source location
Mary WALDRON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of ongoing training in recognition and treatment of acutely unwell residents
Wider context from the report
“(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents; with reliance solely on initial nursing training; ”
Source location
Mary WALDRON · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to embed HSSIB critically unwell patient guidance in staff training

Concerns raised1

Failure to fully roll out required staff training

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents

Concerns raised1

Insufficient clinical staff training in identifying and treating sepsis

Concerns raised1

Poor SANNP and ANNP training in recognition of respiratory distress and PPHN

Concerns raised2

Failure of nursing home staff to recognise acutely unwell residents

Lack of ongoing training in recognition and treatment of acutely unwell residents

Actions described in response 3