Recurring concern
Failure to assure reliable patient observations
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Request correctionFirst reported 5 Sep 2014•Latest report 24 Oct 2025
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.
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.
- Reports
- 9
- Individual concerns
- 10
- Date range
- 2014–2025
- Stated actions
- 15
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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.6
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Action
Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Review Tendable audit templates within the wider Trust audit-assurance process.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.
Stated by Essex Partnership University NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.2
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Action
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Stated by East London NHS Foundation Trust -
Action
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Stated by East London NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Stated by Devon Partnership NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Adopt five-minute observation recording sheets and audit completion at least weekly.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Review observation policy and practices against best-practice standards, guidance and potential digital innovations.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Develop a staff training package and competency assessment framework for therapeutic observations and engagement.
Stated by 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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Position
The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.2
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Action
Carry out a thematic review of CAMHS observation-record audits to identify themes and resulting actions.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Conduct a nationally commissioned independent review of patient services, escalation, oversight and staff culture across Greater Manchester Mental Health NHS Foundation Trust.
Stated by NHS England
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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Position
Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.
Stated by NHS England
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Complete an observations project improving documentation and recognition of EWS at discharge.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Position
The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
Stated by University Hospitals Sussex NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026