Recurring concern

Unreliable assessment of when physiological observations are needed

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First reported 4 Oct 2024•Latest report 31 Oct 2025

Definition

What this concern includes

Includes failures of the clinical decision process for determining whether physiological observations are required or should be repeated, including inadequate symptom enquiry, failure to recognise clinical indications, reliance on subjective or inconsistent thresholds, and failure to establish the need for repeat observations.

Not included

Excludes failures to perform observations after the need and required frequency have been established; those belong to patient-observation performance concerns.
Excludes unclear or absent observation policies or protocols where the unsafe condition is the requirements or guidance themselves rather than failure to assess an individual patient's need.
Excludes failures limited to recording, charting, trending, interpreting or acting on observations that were appropriately initiated.
Excludes generic clinical assessment or training deficiencies that are not specifically tied to deciding whether physiological observations are needed.

Reports: 3
Individual concerns: 4
Date range: 2024–2025
Stated actions: 5

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.

East of England Community Health and Care NHS Trust1

Lancashire Teaching Hospitals NHS Foundation Trust1

Marine Lake Medical Practice1

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.

31 Oct2025
Liverpool and the Wirral
Concerns raised1
1. Failure to establish the timing and need for repeat 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Reiterate to care homes the importance of providing a complete set of observations.
  Stated by Marine Lake Medical PracticeStated planned
AI-generated summary

Gloria SIMON · 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

Gloria Simon moved into a care home for respite on 9 September 2025 and died there from natural causes on 20 September after her condition deteriorated. Concerns included missed opportunities to obtain timely clinical input, the GP’s failure to undertake a face-to-face assessment after misreading oxygen saturation results, and insufficient attention to her medical history and care-home setting.

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 establish the timing and need for repeat observations
Wider context from the report
“2. In its typed ‘Request for Care’ form, the care home noted that Gloria Simon's oxygen saturations were 84% and described them (correctly) as ‘very low’. The time when the observations were taken was not stated. Despite a clerical assistant at the GP practice having not done correctly that the reading was 84%, the GP misread the papers as saying 94% and described the oxygen saturations as ‘low’. The GP told the court that he would have been assisted by knowing the patient's previous medical history and would have acted differently had he known it. However, the records indicate that this information had been supplied by the care home, had been flagged by another GP who made a record on the practice's system, and was available to him. There was no evidence before the court to suggest that the GP had: (a) requested sight of the previous medical history, or made any enquiry about it when (or before) he spoke to a member of staff at the care home; or (b) asked when the observations had been taken or recommended that any further observations should be taken; or (c) asked about whether those observing or caring for the Deceased had any clinical qualifications (having assumed, incorrectly, that she was in a nursing home setting). The court considers that this elderly vulnerable patient should have had a face-to-face clinical assessment but did not because of insufficient attention to detail and/or clinical curiosity on the part of the GP. The court would like to understand how the practice can ensure that this is not something that will recur. ”
Source location
Gloria SIMON · 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
Reiterate to care homes the importance of providing a complete set of observations.

Verbatim wording from the response
“It is noted on the request for care form that several of the parameters were missing. We will reiterate the importance of a full set of observation from staff to care homes, but accept that this may lie outside of the competence of some care home staff. We expect all Marine Lake clinicians to ensure they are comfortable with the clinical information available but not at the detriment of delaying appropriate assessment of the patient.”

Source location
Response from Marine Lake Medical Practice
Page 2 · response
Published 5 November 2025
Open published response
27 Nov2024
Norfolk
Concerns raised2
1. Reliance on subjective clinician judgment for decisions to perform physiological observations
2. Failure to use specific symptom questions when deciding whether physiological observations are required
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Mandate physiological observations during every initial community patient visit and disseminate the updated clinical guidance.
  Stated by East of England Community Health and Care NHS TrustStated completed
2. Action
  Publish and cascade a community patient escalation plan covering deterioration identification, escalation actions and physiological observations.
  Stated by East of England Community Health and Care NHS TrustStated completed
3. Action
  Create a community patient assessment guide containing exploratory questions to identify changes in condition and required further action.
  Stated by East of England Community Health and Care NHS TrustStated in progress
1. Action
  Include the assessment guide and escalation plan in Deteriorating Patient training.
  Stated by East of England Community Health and Care NHS TrustStated planned
AI-generated summary

Kenneth George Willard KING · 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

Kenneth George Willard KING had bilateral leg wounds requiring community nursing care, with delays in some visits and subsequent infection. He was admitted to hospital with cellulitis of both legs and died on 12 November 2023 from septic shock due to bilateral leg cellulitis. Concerns included the absence of a formal structure for physiological observations in community patients and delays in implementing staff training and restrictions on untrained bank staff.

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
Reliance on subjective clinician judgment for decisions to perform physiological observations
Wider context from the report
“1. Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP. No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the attending practitioner relies on general conversation carried out at their attendance to help form a view as to whether observations are required to be taken. It was accepted in evidence that the decision to perform observations relies on the clinical judgment of the relevant clinician, which is a subjective decision which may be exercised incorrectly and at variance with other clinicians. Different clinicians carry out visits in the community and so have no overall view of a patient's presentation and any deterioration. Written records are available but evidence was heard that in this case, on the last visit, the record of the previous attendance was looked at and no history prior to that. Evidence was heard that Health Care Practitioners may have limited clinical training and rely on instructions and advice from trained nurses. In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. ”
Source location
Kenneth George Willard KING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 use specific symptom questions when deciding whether physiological observations are required
Wider context from the report
“1. Evidence was heard that there is no formal structure in place as to when or with regard to the frequency of carrying out physiological observations on patients in the community. Observations are required to be taken if the attending clinician has any concerns about the patient's wellbeing or a deterioration in their condition, or at the request of a senior clinician or GP. No specific questions are asked of the patient, such as if they are feeling unwell, have pain or localised heat, the attending practitioner relies on general conversation carried out at their attendance to help form a view as to whether observations are required to be taken. It was accepted in evidence that the decision to perform observations relies on the clinical judgment of the relevant clinician, which is a subjective decision which may be exercised incorrectly and at variance with other clinicians. Different clinicians carry out visits in the community and so have no overall view of a patient's presentation and any deterioration. Written records are available but evidence was heard that in this case, on the last visit, the record of the previous attendance was looked at and no history prior to that. Evidence was heard that Health Care Practitioners may have limited clinical training and rely on instructions and advice from trained nurses. In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. ”
Source location
Kenneth George Willard KING · 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
Mandate physiological observations during every initial community patient visit and disseminate the updated clinical guidance.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Publish and cascade a community patient escalation plan covering deterioration identification, escalation actions and physiological observations.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Create a community patient assessment guide containing exploratory questions to identify changes in condition and required further action.

Verbatim wording from the response
“A community patient assessment guide is being created which will provide exploratory questions that community staff can use to ascertain any changes in the patient’s condition and identify if any further action is required. Both of these documents and how to use them will be included in the Deteriorating Patient training.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
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
Include the assessment guide and escalation plan in Deteriorating Patient training.

Verbatim wording from the response
“In this case, evidence was heard that Mr King presented as feeling well but had high inflammatory markers, which may mask when observations are required to be carried out. Some patients may not be forthcoming about any symptoms unless specifically asked. Trust guidance was updated and disseminated to all clinical staff to mandate the completion of physiological observations on every initial patient visit with immediate effect. A community patient escalation plan has been published and cascaded to support staff in identifying patients at risk of deterioration and the escalation actions that are required which includes the completion of physiological observations.”

Source location
Response from Norfolk Community Health & Care NHS Trust
Page 2 · response
Published 2 December 2024
Open published response
4 Oct2024
Lancashire and Blackburn with Darwen
Concerns raised1
1. Lack of nursing knowledge about when basic asthma assessments should be taken
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 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

Marina Sharon Young · 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

Marina Sharon Young, who had spina bifida and asthma, died after spending 39 hours in the Accident & Emergency Department during an asthma attack. The report describes failures in medical management, escalation to specialist teams, nursing assessment, and provision of care for her complex needs, including catheterisation, pressure-area care and toileting. The concerns include inadequate assessment and management of patients held in A&E beyond the expected time, insufficient asthma expertise, and failures to escalate concerns.

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 nursing knowledge about when basic asthma assessments should be taken
Wider context from the report
“4. Asthma is a common condition. However, A & E lacked nurses with any knowledge of when basic assessment such as peak flow should be taken and no request for assistance from a specialist ward was made. ”
Source location
Marina Sharon Young · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to establish the timing and need for repeat observations

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

Concerns raised2

Reliance on subjective clinician judgment for decisions to perform physiological observations

Failure to use specific symptom questions when deciding whether physiological observations are required

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.4

Concerns raised1

Lack of nursing knowledge about when basic asthma assessments should be taken

Actions described in response 1

Actions described in response 4