Recurring concern

Failure to escalate deteriorating patients for ICU involvement

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First reported 16 Oct 2017•Latest report 17 Jul 2023

Definition

What this concern includes

Includes only assertions that directly instantiate the manually reviewed condition ‘Failure to escalate deteriorating patients for ICU involvement’ and satisfy this evidence boundary: Two distinct reports support missing doctor-to-doctor discussion of potentially beneficial ICU involvement and failure to pursue alternative escalation when ICU outreach is unavailable. Excludes the assertion about escalation within ICU, which concerns care after ICU involvement has already begun. Keep memberships distinct from the outreach-service parent at position 398.

Not included

Excludes generic clinical deterioration or escalation failures where intensive care involvement or support is not materially identified.
Excludes general ICU staffing or capacity deficiencies unless they directly impair escalation to, within or from intensive care support.
Excludes failures in ICU treatment after appropriate escalation and senior review have already occurred.
Excludes generic doctor-to-doctor communication or multidisciplinary-working failures that are not specifically connected to intensive care escalation or support.
Excludes manifestations outside the manually reviewed boundary: Two distinct reports support missing doctor-to-doctor discussion of potentially beneficial ICU involvement and failure to pursue alternative escalation when ICU outreach is unavailable. Excludes the assertion about escalation within ICU, which concerns care after ICU involvement has already begun. Keep memberships distinct from the outreach-service parent at position 398.

Reports: 3
Individual concerns: 3
Date range: 2017–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Great Western Hospitals NHS Foundation Trust1

NHS England1

Tameside and Glossop Integrated Care NHS Foundation Trust1

Tameside General Hospital1

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.

17 Jul2023
Manchester South
Concerns raised1
1. Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Maintain a critical-care referral policy defining consultant-to-consultant and urgent medical-registrar referral pathways.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The concerns fall under the Trust’s remit rather than NHS England’s functions.
  Stated by NHS EnglandOutside remit
1. Position
  The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Jane Elizabeth Wadsworth · 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

Jane Elizabeth Wadsworth became seriously unwell after elective hip surgery, developing a deep vein thrombosis, cellulitis, sepsis, acute kidney injury and liver failure, and died on 31 December 2022 despite intensive care treatment. Concerns included missed antibiotic doses, limited consultant input, unclear escalation and doctor-to-doctor discussion about intensive care, unavailable Critical Care Outreach support, and no evidence that specialist liver advice was obtained.

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 conduct effective doctor-to-doctor discussion of potential ICU involvement
Wider context from the report
“3. The junior doctor involved in her care felt that ICU involvement/input would be beneficial. The evidence was that there did not seem to be any doctor to doctor discussion of this. The inquest heard evidence that this was one way a patient could be transferred to ICU. It was unclear why there had not been such a discussion and whether in periods such as Christmas/ New Year where there were fewer consultants available the system worked effectively. This was not a situation where there had been a ward based ceiling of care put in place and ultimately Mrs Wadsworth was treated by ICU but was extremely unwell at that point and did not respond to that intervention at that point; ”
Source location
Jane Elizabeth Wadsworth · Prevention of Future Deaths report
Page 3 · 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
Maintain a critical-care referral policy defining consultant-to-consultant and urgent medical-registrar referral pathways.

Verbatim wording from the response
“The Admission and Discharge Policy for Critical Care clearly sets out referral pathways for those patients who may require a higher level of care leading critical care due to their current clinical condition. The referral pathway is in line with national guidance (National Confidential Enquiry into Perioperative Deaths- NCEPOD, The National Institute for Health and Care Excellence- NICE, National Patient Safety Agency-NPSA, and Royal College Physicians) that the optimal referral pathway is consultant to consultant. However the policy describes that in more critical instances where any delay may be detrimental to the patient then a referral may come from training grade doctors. It is expected that this be a medical registrar (i.e. medical middle grade either on-call or responsible for the patient).”

Source location
Response from Tameside and Glossop Integrated Care
Page 5 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The concerns fall under the Trust’s remit rather than NHS England’s functions.

Verbatim wording from the response
“The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.

Verbatim wording from the response
“The matters of concern raised in your Report come under the remit of Tameside and Glossop Integrated Care NHS Foundation Trust (hereafter “the Trust”), who are therefore the appropriate organisation to respond to the concerns raised. I am however grateful to you for bringing these important patient safety issues to my attention. The concerns have been shared with my relevant regional Quality colleagues in the North West, who are engaging with Greater Manchester Integrated Care Board (the responsible commissioning body for Greater Manchester) about the issues raised.”

Source location
Response from NHS England
Page 1 · response
Published 21 July 2023
Open published response
10 Jan2019
Manchester South
Concerns raised1
1. Failure to explore alternative escalation routes when ICU outreach is unavailable
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michael William Flynn · 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

Michael William Flynn underwent elective hip replacement surgery and required a blood transfusion. He subsequently experienced inadequate Early Warning Score monitoring, failures to follow escalation procedures, incomplete fluid-balance monitoring, and a lack of timely clinical review before suffering cardiac arrest and dying on 17 July 2018.

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 explore alternative escalation routes when ICU outreach is unavailable
Wider context from the report
“9. The trust had an ICU out reach team whose role was to support units such as the orthopaedic unit. However the team was not available when contacted due to staffing issues. Alternative escalations routes were not explored. ”
Source location
Michael William Flynn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Oct2017
Wiltshire and Swindon
Concerns raised1
1. Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Operate a 24-hour continuity plan that routes critical-care support to ITU nursing or ICU medical staff when outreach is unavailable.
  Stated by Great Western Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Existing continuity and escalation arrangements ensure staff are always available to support escalation when critical care outreach is unavailable.
  Stated by Great Western Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Jeremy Michael Holt · 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

Jeremy Michael Holt Marshall developed a small bowel obstruction and other complications after elective surgery for colonic adenocarcinoma, deteriorated in hospital, and died on 17 November 2016 after life support was withdrawn. Concerns included delays in escalating his deteriorating condition, insufficiently specified review and fallback arrangements, and inadequate recording of observations for a critically ill patient with a high NEWS score.

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
Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient
Wider context from the report
“2. Review Point and fall back position when no further action is forthcoming – ████████ and also ████████ care plan at midnight provided for action to be undertaken but neither care plan provided for a specific timescale for any further review in respect of a patient who was quite clearly critically ill. Both ████████ indicated that with the benefit of hindsight that such a timescale would have been desirable. I am concerned that if there is not a review or further action undertaken and noted within a period of time which at the end of the day has to be reasonable but given the critical nature of patient scoring 7 and above should be relatively short, that if nothing happens that the nursing staff are empowered to refer the matter now to the Critical Care Outreach Team. My concern goes further than that. If hypothetically the Critical Care Outreach Team at a time of significant demand were unable to assess a patient then there needs to be built into that system a fallback position similar to the same fallback position that is available to the doctors ie that the nursing team can contact ITU or even as a last resort on the call Consultant. I am satisfied and I have no doubt in my similar situation that ████████ would have no hesitation in making such a call but I am concerned as to whether or not other members of the nursing team would be aware of those options and that is of concern to me as well as the reinforcement of a review point for a critically ill patient to be actually recorded in the care plan. ”
Source location
Jeremy Michael Holt · 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
Operate a 24-hour continuity plan that routes critical-care support to ITU nursing or ICU medical staff when outreach is unavailable.

Verbatim wording from the response
“The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing continuity and escalation arrangements ensure staff are always available to support escalation when critical care outreach is unavailable.

Verbatim wording from the response
“The Trust has a continuity plan in place so that if the critical care outreach team are not available the bleep is passed to the nurse in charge of ITU or the ICU doctor. This ensures that there is always staff available to provide support when required. The system has been operational 24 hours a day since January 2017 and therefore has been in place during period of winter pressure and has proved to be an effective and beneficial resource in improving patient safety. This is demonstrated by review of ITU admissions and the latest report shows that for the unplanned admissions there is an improving trend in the medical plans being documented and appropriate escalation being undertaken. In addition the number of medical emergency team calls has reduced.”

Source location
2017-0296-Response-by-The-Great-Western-Hospital-NHS-Trust
Page 3 · response
Published 18 December 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to conduct effective doctor-to-doctor discussion of potential ICU involvement

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to explore alternative escalation routes when ICU outreach is unavailable

Concerns raised1

Lack of an available and understood fallback escalation pathway when Critical Care Outreach cannot assess a patient

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Respondent positions 2

Actions described in response 1

Respondent positions 1