Recurring concern
Unreliable post-operative monitoring and clinical review
- Reports that mention this concern
- 13
- Times this concern has been raised
- 17
- Stated actions linked to this concern
- 32
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 13 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Failure to inspect the surgical wound
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
-
The Trust
Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.
-
The Trust
Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.
-
The Trust
Review wound-care documentation, care plans and wound-assessment standards.
-
The Trust
Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.
-
The Trust
Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.
-
Concerns raised1
Failure to report post-operative observations to medical staff when EWS is rising
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of Leicester NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
University Hospitals of Leicester NHS Trust
Provide continuous teaching for Clinical Management Group staff on interventional radiology procedures, complications, observation frequencies, complication recognition and escalation.
-
University Hospitals of Leicester NHS Trust
Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.
-
University Hospitals of Leicester NHS Trust
Rewrite the EWS training package to clarify actions when scores are unreliable or require escalation, incorporating learning from the case.
-
Concerns raised1
Failure to assess and monitor post operative fluid balance
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Survey and Sussex NHS Healthcare NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
-
Survey and Sussex NHS Healthcare NHS Trust
Implement national-standard Early Warning Score paperwork and provide recurring staff training on deterioration recognition and fluid-balance monitoring.
-
Survey and Sussex NHS Healthcare NHS Trust
Provide Sepsis, Acute Kidney Injury and fluid-balance monitoring study days for ward nurses.
-
Survey and Sussex NHS Healthcare NHS Trust
Deliver ward-based teaching on patient assessment, acute kidney injury and fluid balance, with further sessions planned during 2015.
-
Survey and Sussex NHS Healthcare NHS Trust
Restart ALERT courses covering deterioration recognition, acute kidney injury and fluid-balance charts.
-
Survey and Sussex NHS Healthcare NHS Trust
Start BEACH courses in April 2015, including fluid-balance monitoring training.
-
Survey and Sussex NHS Healthcare NHS Trust
Conduct a Trust-wide audit of fluid-balance chart completion during 2015.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026