Recurring concern
Failure to assure reliable patient observations
- Reports that mention this concern
- 9
- Times this concern has been raised
- 10
- Stated actions linked to this concern
- 15
What this concern includes
Includes management checks, audits and other assurance controls specifically dedicated to verifying the completion, frequency, adequacy or documentation of required patient observations.
What is not included
- Excludes failures of the observations themselves when no assurance, audit or verification deficiency is identified.
- Excludes generic care auditing, documentation review or management oversight not specifically tied to patient observations.
- Excludes failures limited to setting observation frequency or risk level unless the report also identifies a dedicated assurance or verification failure.
- Excludes non-patient monitoring and checking processes.
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 9 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Omission of quality and nature audits from observation records auditing
Failure of quality assurance and auditing processes to monitor the quality of observations and engagement documentation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Essex Partnership University NHS Foundation 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
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Essex Partnership University NHS Foundation Trust
Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.
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Essex Partnership University NHS Foundation Trust
Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.
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Essex Partnership University NHS Foundation Trust
Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.
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Essex Partnership University NHS Foundation Trust
Review Tendable audit templates within the wider Trust audit-assurance process.
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Essex Partnership University NHS Foundation Trust
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
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Essex Partnership University NHS Foundation Trust
Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.
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Concerns raised1
Failure of spot checks to identify and address falsified observation records
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East London NHS Foundation 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.2
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East London NHS Foundation Trust
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
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East London NHS Foundation Trust
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
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Concerns raised1
Lack of clarity over responsibility for checking observation charts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Devon Partnership 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.1
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Devon Partnership NHS Trust
Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
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Concerns raised1
Failure of 1:5 observation records to evidence five-minute checks
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Greater Manchester Mental Health NHS Foundation 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
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Greater Manchester Mental Health NHS Foundation Trust
Adopt five-minute observation recording sheets and audit completion at least weekly.
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Greater Manchester Mental Health NHS Foundation Trust
Review observation policy and practices against best-practice standards, guidance and potential digital innovations.
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Greater Manchester Mental Health NHS Foundation Trust
Develop a staff training package and competency assessment framework for therapeutic observations and engagement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Greater Manchester Mental Health NHS Foundation Trust
The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.
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Concerns raised1
Failure to conduct higher-level investigations into patterns of missed observations and falsified records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Greater Manchester Mental Health NHS Foundation Trust
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Greater Manchester Mental Health NHS Foundation Trust
Carry out a thematic review of CAMHS observation-record audits to identify themes and resulting actions.
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NHS England
Conduct a nationally commissioned independent review of patient services, escalation, oversight and staff culture across Greater Manchester Mental Health NHS Foundation Trust.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS England
Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.
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Concerns raised1
Failure of management records and checks to verify required observations
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Unsatisfactory auditing of compliance with safe discharge arrangements and recording of the Early Warning Score on discharge
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals NHS Foundation 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.1
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Complete an observations project improving documentation and recognition of EWS at discharge.
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Concerns raised1
Failure of Senior Nurse verification and completion of N.E.W.S. scores
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Sussex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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University Hospitals Sussex NHS Foundation Trust
The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
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Concerns raised1
Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026