Recurring concern
Failure to ensure staff competence in conducting and interpreting clinical observations
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Request correctionFirst reported 23 Oct 2013•Latest report 2 Jan 2025
What this concern includes
Includes failures of training, induction, guidance, competence assessment or supervision that leave staff unable to conduct, understand, interpret or appropriately escalate required clinical observations, including physiological, neurological, enhanced and procedure-related observations.
Not included
- Excludes failures to perform or record observations where staff competence is not the identified unsafe condition.
- Excludes generic staffing shortages, documentation failures or equipment defects unless they directly cause inadequate staff competence in conducting or interpreting clinical observations.
- Excludes failures of named early-warning, triage or condition-specific observation systems when the system itself, rather than staff competence, is the supported concern.
- Excludes failures to act on correctly performed and understood observations where the observation competence process was adequate.
- Reports
- 10
- Individual concerns
- 10
- Date range
- 2013–2025
- Stated actions
- 13
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 raised1
Failure to provide and verify support workers’ training and competence for physical health checks
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of training and awareness that clot-related abnormal observations can normalise
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.
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Concerns raised1
Lack of warning or training for clinical staff on interpreting respiratory effort
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 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
Lack of staff training and competency assessment for carrying out observations
This report raised 8 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
Deliver ward-specific Safety Day training on clinical risk, care planning, incident learning and therapeutic observations.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Refresh staff understanding of the therapeutic observations policy through competency reassessment.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Review the Therapeutic Observations Policy to consider strengthened training, documentation, ward controls, staff guidance and assurance processes.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Lack of staff training and knowledge in conducting neuro observations
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.5
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Action
Deliver rolling falls-management training covering risk reduction, post-fall care, unwitnessed falls and neuro-observations to mental-health nursing staff.
Stated by Cardiff & Vale University LHB -
Action
Operate a falls-simulation training suite providing workshops on falls prevention, post-fall care, unwitnessed falls and head-injury response.
Stated by Cardiff & Vale University LHB -
Action
Use a new neuro-observation chart and restrict neuro-observation performance to registered nurses under UHB policy.
Stated by Cardiff & Vale University LHB
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Action
Include neuro-observation procedures in the undergraduate nursing curriculum.
Stated by Cardiff & Vale University LHB -
Action
Pursue appropriate regulatory concerns concerning the nurses through fitness-to-practise procedures.
Stated by Nursing and Midwifery Council
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 health board is responsible for explaining nurses’ relevant training and any steps taken to learn from the incident.
Stated by Nursing and Midwifery Council
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Concerns raised1
Lack of training on completing and recording enhanced observations
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.2
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Action
Trial amended enhanced-observation documentation with guidance, actual observation times, staff coaching, monitoring and evaluation.
Stated by Heatherwood Court Hospital and Ludlow Street Healthcare -
Action
Update the training package with instructional video and completed-documentation exemplars.
Stated by Heatherwood Court Hospital and Ludlow Street Healthcare
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Concerns raised1
Failure of hospital systems to identify nurses lacking the competence or training for basic observations
This report raised 10 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
Deliver Trust-wide neurological-observation training for registered nurses, including competence testing.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Lack of understanding of required observations during the procedure
This report raised 7 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
Maintain a cardiology guideline for intravenous conscious sedation covering dose titration, monitoring, observation frequency and training.
Stated by Frimley Health NHS Foundation Trust -
Action
Review and revise the Trustwide guideline for intravenous conscious sedation across clinical settings to standardise processes.
Stated by Frimley 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
A cardiology intravenous conscious sedation guideline existed at the time and addressed many concerns raised at the inquest.
Stated by Frimley Health NHS Foundation Trust
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Concerns raised1
Failure to include required observations and recording in resuscitation training
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of consistent nursing staff understanding of intermittent observation requirements during patient bathing
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026