Recurring concern

Failure to reliably communicate clinically significant patient observations to medical staff

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First reported 2 Apr 2014•Latest report 27 Oct 2023

Definition

What this concern includes

Includes failures of the dedicated process for recognising and communicating clinically significant patient observations or changes to medical staff, including abnormal temperature, rising early warning scores and other observations requiring medical review.

Not included

  • Excludes failures to perform or obtain the observation when the observation was not completed; those belong to patient-observation performance or monitoring concerns.
  • Excludes failures limited to recording, charting or preserving observations when communication to medical staff was not deficient.
  • Excludes failures to assess, treat or act on an observation after it was reliably communicated.
  • Excludes generic communication or staffing deficiencies without a direct patient-observation communication or escalation failure.
  • Excludes non-patient observations and observations not requiring communication to medical staff.
Reports
16

Distinct published reports

Individual concerns
17

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
28

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.

General Medical Council2
Nursing and Midwifery Council2
University Hospitals Sussex NHS Foundation Trust2
Amberley Hall Care Home1
Athena Care Homes (UK) Limited1
Belmarsh Prison1
Care Quality Commission1
Cwm Taf Morgannwg University Local Health Board1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Great Western Hospitals NHS Foundation Trust1
Holy Cross Hospital1
Liverpool University Hospitals NHS Foundation Trust1
NHS Cheshire and Merseyside Integrated Care Board1
NHS England1
Public Health England1

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. Leicester City and South Leicestershire

    AI-generated summary

    Alan Tear · 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

    Alan Tear was receiving palliative treatment for cholangiocarcinoma and died after a biliary drain insertion. He died from an intraperitoneal bleed caused by a misplaced drain and peritoneal perforation. Concerns included missed post-operative observations, failure to report a rising EWS to medical staff, and unclear communication between the interventional radiology and nursing teams.

    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 report post-operative observations to medical staff when EWS is rising

    Wider context from the report

    “2. Post-operative observations were not reported to medical staff as required when the EWS was rising. ”

    Source location

    Alan Tear · 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

    Provide continuous teaching for Clinical Management Group staff on interventional radiology procedures, complications, observation frequencies, complication recognition and escalation.

    Verbatim wording from the response

    “Additionally, as part of our wider learning, our Clinical Director for the Clinical Management Group (CMG) will, along with the Medical Lead for Imaging ensure that there is a continuous teaching session for CMG staff on the issue of Interventional Radiology for Surgical patients; describing the technique, complications, frequency of observation for each different procedure, identification of complications and escalation. This will have occurred before the end of December 2015.”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 2 · response
    Published 14 October 2015

    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

    Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.

    Verbatim wording from the response

    “As a result of this inquest we will be redesigning the sheet which documents the required frequency of observations to be undertaken on the receiving ward. The sheet and required frequency will vary according to the type of the procedure performed. To optimise the hand over the sheet will be signed by the Interventional radiology nurse and receiving ward at the radiology theatre. Our Medical Lead for Imaging, in consultation with surgical colleagues, will have completed this work by the end of December 2015.”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 2 · response
    Published 14 October 2015

    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

    Rewrite the EWS training package to clarify actions when scores are unreliable or require escalation, incorporating learning from the case.

    Verbatim wording from the response

    “However we remain committed to improving our on-going education at the Trust on the EWS scoring tool. Our Interim Deputy Medical Director and Assistant Chief Nurse are currently rewriting the EWS training package and will use what occurred in this case to ensure that clinical staff are given clarity on the actions that they must take when there is either doubt as to the reliability of any particular EWS score or the EWS score is considered to require escalation. This work is due to be completed by the end of March 2016.”

    Source location

    Response from University Hospitals of Leicester NHS Trust
    Page 3 · response
    Published 14 October 2015

    Open published response

  2. Inner South London

    AI-generated summary

    Laurence Boyens · 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

    Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

    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 communicate and define reporting parameters for pre-administration blood-pressure readings

    Wider context from the report

    “1. There appeared to be a general misunderstanding how health care professionals should comply with DH Clinical Management of Drug Dependence in Adult Prison Settings Guidelines 12.3 and 12.4. In particular this relates to the requirement to ensure that patients who are undergoing Methadone or Buprenorphine stabilization have not experienced a lowering of blood pressure or drowsiness before administration of the controlled drug. • Health care assistants routinely took the blood pressure before administration but did not inform the nurse of the reading and may not have had instruction when to report the reading • The evidence of six nurses and a health care assistant showed that previous blood pressure recordings were not sought or examined to determine if there had been a lowering of BP • The record of blood pressure was often written on paper and not usually entered in the medical records at the time and sometimes not at all • A health care assistant who did record a BP of 93/68 was asked by a nurse to repeat it and reported back to the medication hatch that it was still low. No apparent action was taken by nurses to suspend the medication or escalate the concern to a doctor on 11th. • One nurse, who did not see the BP of 93/58 recorded in the records and administered Methadone, did not know what she would do if he had discovered a previous higher BP. • One nurse was surprised that a BP of 105/60 having a reading of 128/68 and 93/68 the previous day and 121/81 the day before that, should trigger withholding Methadone and escalating to the doctor. • The expert GP, who had been clinical director in the health care team provided to the prison, identified a sequence of seven BP recordings over 4 days, six of which (the second was considered rogue) should have triggered suspension of administration of drugs and escalation to the doctor, but in no case did this occur. • The head of health care at the time, who was an inexperienced nurse, did not accept that advice and asserted it would be impractical to implement it, as it would lead to significant delays. • In a local policy on Buprenorphine a threshold triggering suspension of drug and escalation was defined as 90/60 without reference to the trend. None was found in a section on Methadone and no definition of lowering of blood pressure or how to record it was found in any local policies. • No nurse saw the entry in the medical records by a doctor at 18.56 on 13th November which read: “Unusually drowsy. Eyelids close when not engaged. communicative alert. no sadness or dsh. Plan stop Citalopram and monitor for signs of overdose.. may req further urine test before further Methadone testing...”. • At 17.57 on 13th, one hour from the doctor’s assessment, when he must have been unusually drowsy, no nurse found him drowsy when he presented at the hatch for medication, and he was given Methadone and Tramadol. • On the morning of 14th he was given further Methadone and Tramadol, without measuring the blood pressure, or testing, as the previous day was last day of his Methadone titration regime and his 5 day review. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    Philip Robinson · 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

    Philip Robinson developed vomiting, breathlessness, coughing up blood and pain before being assessed at Bassetlaw Hospital, discharged, and later readmitted in cardiac arrest. The inquest concluded that he died from an acute myocardial infarction with severe coronary artery disease, after the significance of his clinical condition was not appreciated by the treating team. Concerns included inadequate escalation and recording of Early Warning Scores, unclear guidance on ECG use, an extreme risk arising from the absence of senior medical review, and incomplete implementation of systems intended to improve monitoring.

    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 reliably record and communicate the Early Warning Score across healthcare staff

    Wider context from the report

    “The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital ”

    Source location

    Philip Robinson · 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

    Embed ward safety briefings and provide education to improve multidisciplinary communication of EWS.

    Verbatim wording from the response

    “• The improved recording and communication of the EWS from Health Care assistant, to Nurse, to doctor as necessary, is not evident throughout the Hospital The safety brief at the end of the ward round involves the whole of the ward team including HCA’s to improve communication of EWS between all the Multi-disciplinary team. The observations project has been completed and education undertaken with respect to the importance of clear communication between all members of the team. A safety brief is embedded in practice between shift change overs to improve whole team awareness of issues on the whole unit. Audits on ATC of documentation of EWS by HCA in the notes have consistently improved, reducing the chance of verbal communication failure. Recent audits show 100% compliance with the escalation policy on ATC.”

    Source location

    2015-0225-Response-by-Doncaster-Bassetlaw-Hospitals-NHS-Trust
    Page 2 · response
    Published 13 March 2015

    Open published response

  4. Brighton and Hove

    AI-generated summary

    LINDA ANNE RIGNALL · 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

    Linda Anne Rignall's condition changed on 5 May 2014, but the change was not reported to a doctor and she was not assessed; her condition worsened approximately four hours later without a medical review. The report states that this failure to refer her for assessment resulted in the only available window of opportunity to treat her being lost, raising concern about the Acute Medical Unit's fitness for purpose.

    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 changes in patient condition for timely medical assessment

    Wider context from the report

    “(1) At 17:33 on the 5th May 2014, Linda Rignall's condition changed and this was recorded on the NEWS Observation chart. This change in condition should have been reported to a Doctor on the Acute Medical Unit and she should have been assessed. The position worsened some 4 hours later (the next time observations were performed) and there was still no request for a medical review. From the evidence it was clear to me and I found as you will see from the Conclusion that I recorded that this failure to refer Miss Rignall for assessment resulted in the only window of opportunity available to treat her, being lost. This makes me concerned as to AMU's Fitness for Purpose at the current time. I consider this to be serious. ”

    Source location

    LINDA ANNE RIGNALL · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Thomas Charles TAYLOR · 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

    Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

    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 alert medical staff after significant hyperglycaemia

    Wider context from the report

    “3. When Mr Taylor refused to have his blood sugar checked, there seemed no well understood protocol for re-checking or escalation. Immediate provision was not made for the administration of insulin, and a doctor was even told that he was not diabetic. When Mr Taylor became significantly hyperglycaemic on the 22nd, after the administration of the delayed dose of insulin his nurses did not immediately re-check his blood sugar, perform neurological observations or alert medical staff. ”

    Source location

    Thomas Charles TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Black Country

    AI-generated summary

    Mr John Dodd · 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

    Mr John Dodd died from a retroperitoneal haemorrhage at Russells Hall Hospital on 21 April 2013, after being admitted through A&E the previous day. Concerns included that his INR was not checked while he was taking Warfarin, a documented temperature rise was not reported to medical staff before discharge, and there was a delay in his first assessment during his final admission, which was said to have delayed investigation and diagnosis.

    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 report a documented temperature rise to medical staff

    Wider context from the report

    “The deceased was on Warfarin but the INR was not checked on 16 April 2013 despite the degree of pain and the history of fall. There was a rise in temperature of nearly 1 degree on the afternoon of 16 April 2013 documented by the IMPACT team which was not reported to the medical staff. This was against a background of paracetamol being administered. It was the evidence of ████████ that he would have wanted to know about this and would have wanted the patient reassessed medically prior to the actual discharge from the department. This did not happen, Mr. Dodd having been declared medically fit for discharge prior to the referral to the IMPACT team. There was a considerable delay on the night of the 20 April between the arrival of Mr. Dodd in A&E and his first assessment by a medically qualified member of staff vis: 20:44 – 00:23. It was the evidence of ████████ that this was inappropriate, and clearly led to a delay in investigation and diagnosis. ”

    Source location

    Mr John Dodd · 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

    Use an electronic-system prompt to indicate when abnormal observations need communicating to senior staff.

    Verbatim wording from the response

    “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.”

    Source location

    2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
    Page 2 · response
    Published 2 April 2014

    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

    Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.

    Verbatim wording from the response

    “• The Emergency Department will continue to monitor vital signs within nationally recognised guidelines, and a prompt has been incorporated in the clinical electronic information system to indicate the need to communicate abnormal observations to senior staff. Regular board rounds are now in place to ensure that each patient is discussed regularly with senior medical staff.”

    Source location

    2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
    Page 2 · response
    Published 2 April 2014

    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

    Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.

    Verbatim wording from the response

    “• The electronic clinical information system used by the Emergency Department will be reconfigured to create a visible alert to the consultant in charge, when a patient’s vital signs fall outside normal parameters.”

    Source location

    2014-0145-Response-by-The-Dudley-Group-NHS-Foundation-Trust
    Page 2 · response
    Published 2 April 2014

    Open published response
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Data last updated 7 September 2026