First reported 27 Jan 2015•Latest report 13 Dec 2024
Definition
What this concern includes
Includes failures in dedicated post-operative monitoring and clinical review, including required observations and early-warning checks, suitable monitoring environments, additional monitoring for relevant vulnerabilities, and adequate medical oversight of post-operative reviews.
Not included
Excludes failures in the operation itself or pre-operative assessment.
Excludes general post-operative treatment, wound care, discharge, rehabilitation or long-term follow-up where monitoring or clinical review is not the deficient control.
Excludes generic staffing, communication, documentation or care-planning deficiencies unless they directly impair post-operative monitoring or clinical review.
Excludes failures after adequate monitoring and review have identified deterioration where the remaining issue is treatment or escalation.
Reports
13
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2015–2024
First to latest report issue date
Stated actions
32
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.
Barking, Havering and Redbridge University Hospitals NHS Trust1
British Society Of Gastroenterology1
Cornwall Partnership NHS Foundation Trust1
Department of Health and Social Care1
East Surrey Hospital1
Homerton Healthcare NHS Foundation Trust1
Independent Healthcare Providers Network1
Manchester University NHS Foundation Trust1
Medway NHS Foundation Trust1
Moorfields Eye Hospital NHS Foundation Trust1
Portsmouth Hospitals University NHS Trust1
Ramsay Health Care UK1
Recipient name withheld1
Royal College of Pathologists1
Royal College of Radiologists1
NHS trust8
Healthcare site3
Company1
Health professional body1
Ministerial department1
Registered charity1
Trade association1
Type not available1
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.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to ensure specialist bariatric team review of post-operative gastric bypass 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
Cornwall and Isles of Scilly
Concerns raised1
Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Transfer to Derriford Hospital was correct because urgent assessment was required and it provided the closest prompt access to acute care.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Community-based care and transfer to Liskeard were appropriate because there was no urgent need for orthopaedic revision surgery.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Further liaison with the Royal Cornwall Hospitals orthopaedic team was not clinically needed until around the later transfer period.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
North London
Concerns raised1
Lack of consideration of additional post-operative monitoring and requirements for patients with HbSS
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.
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
Action
Update the Elective Liver Biopsy SOP to require enhanced risk assessment, specialist MDT discussion, pre-assessment, relevant monitoring, and reference to current professional guidance.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
Teesside and Hartlepool
Concerns raised1
Insufficient vigilance and recognition of post-operative presentation
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.
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
Action
Develop and provide patients and carers with a postoperative sepsis-awareness information card.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Action
Implement the Call 4 Concern initiative, enabling patients and families to request Critical Care Outreach review.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Action
Raise awareness among patients and families that the Call 4 Concern option is available.
Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2024.
Inner North London
Concerns raised1
Lack of post-operative checks for air embolism
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Cease undertaking further endoresection procedures of this nature.
Stated by Moorfields Eye Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust cannot provide enhanced postoperative monitoring and intensive care support because it lacks the necessary facilities.
Stated by Moorfields Eye Hospital NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised2
Failure to provide or rearrange consultant review after the post operative area
Failure to monitor and incorporate observations into an EWS in the post operative recovery area
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.
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.8
Action
Review and revise consultant job plans to support consultant ward-round availability, subject to management approval.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Develop a triggered referral process to orthogeriatricians for patients requiring senior review.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
Action
Provided feedback to staff involved in post-operative recovery documentation.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Communicated theatre documentation and NEWS escalation expectations through a team meeting and staff memo.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Commissioned an audit of post-operative recovery documentation compliance.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Introduced formal telephone handover of NEWS scores and management plans for high-risk transfers.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Introduced joint transfer observations and assessment for high-risk patients, with compliance monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Post-operative recovery does not use the NEWS escalation process because patients are continuously monitored and an anaesthetist is immediately available.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Lack of specialised nursing expertise for post-operative patients at risk of leak or sepsis
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.
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
Action
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Stated by Independent Healthcare Providers NetworkStated plannedThe respondent said that this action was planned when they made their response on 12 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Multi-skilled independent-sector nurses are trained and assessed to identify complications and care for acutely ill patients; their broad competencies are considered a strength.
Stated by Independent Healthcare Providers NetworkDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to emphasise review of post-operative prophylaxis after discharge home
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NICE concluded that its VTE guidelines are appropriate and require no amendment at this time.
Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.
East London
Concerns raised3
Failure to document post-operative checks
Failure to carry out compliant post-operative checks
Unavailability of an appropriate environment for post-operative monitoring
This report raised 5 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.
Manchester South
Concerns raised2
Lack of adequate medical oversight of first post-operative reviews
Failure to ensure adequate medical oversight of nurse-led patient discharges
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Strengthen post-operative clinics by having a consultant present alongside nurse-led reviews, including the first post-operative review.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Nurse-led post-operative clinics are considered adequate because trained nurses conduct reviews with consultant support and strengthened same-clinic consultant presence.
Stated by Manchester University NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Discharge at the February 2016 review was considered appropriate because imaging was compatible with normal post-operative findings and histology remained pending.
Stated by Manchester University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures in dedicated post-operative monitoring and clinical review, including required observations and early-warning checks, suitable monitoring environments, additional monitoring for relevant vulnerabilities, and adequate medical oversight of post-operative reviews.
