Recurring concern

Failure to take timely escalation action when safety thresholds are breached

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First reported 27 Jan 2014•Latest report 16 Mar 2026

Definition

What this concern includes

Includes failures to initiate, progress or complete escalation when a defined safety threshold, failed contact or time limit has been reached, including escalation after repeated failed visits, breached response times or comparable triggers requiring senior review, resource allocation or welfare intervention.

Not included

  • Excludes the underlying safety concern, staffing shortage or clinical deterioration when no failure to escalate after a defined trigger is identified.
  • Excludes failures of ordinary communication or notification where no safety threshold, failed contact or breached time limit required escalation.
  • Excludes deficiencies confined to the substantive content of an escalation policy when the policy's operation after a trigger is not the unsafe condition.
  • Excludes the existing broader concern about failure to escalate patient-safety concerns to senior oversight when the assertion does not specifically identify a breached threshold, failed contact or time-based escalation trigger.
Reports
62

Distinct published reports

Individual concerns
65

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
84

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6
NHS England5
Barts Health NHS Trust3
Care Quality Commission3
North West Ambulance Service NHS Trust3
East Midlands Ambulance Service NHS Trust2
Essex County Council2
Essex Partnership University NHS Foundation Trust2
Manchester University NHS Foundation Trust2
South East Coast Ambulance Service NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Adbolton Hall1
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bedford Prison1

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.

  1. Brighton and Hove

    AI-generated summary

    Herta Edith Maria WOODS · 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

    Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

    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

    Wider context from the report

    “(4) Failure to act on the NEWS score and create a plan for Mrs. Woods and assist her. This lady was very likely near the end of her life. However, from the evidence that I heard, it was clear that she would not have died when she did had she been given appropriate care and treatment. ”

    Source location

    Herta Edith Maria WOODS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Pamela Margaret Bailey · Prevention of Future Deaths report

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

    Report summary

    Pamela Margaret Bailey left Hawthorn Ward, Northern General Hospital, on 23 March 2013 and was later found deceased at a secluded location near Ladybower, Derbyshire, on 29 March 2013. The medical cause of death was hypothermia. The substantive concerns included ward door security, staffing levels, and the absence of a photograph available to police when she disappeared.

    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 unsuccessful staffing replacement efforts to senior management

    Wider context from the report

    “(2) On Saturday 23rd March 2013 the staffing on Hawthorn Ward was only three, whereas it should have been (at least) four. Attempts had been made by the previous shift to obtain a replacement, although it had not involved contacting senior management, having failed to obtain a replacement by contacting either existing staff or flex staff. The Action Plan reveals that as regards staffing there is a proposal that there will be no difference between weekdays and weekends, as is now the case. It also indicates that a senior manager is to be made available to manage and not as now also involved in clinical duties. Please confirm what action is to take place. ”

    Source location

    Pamela Margaret Bailey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026