Recurring concern

Unreliable clinical review of observation charts

First to latest report 2 Feb 2016 — 2 Dec 2023

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 1

What this concern includes

Includes failures of the process for reviewing and assessing completed patient observation charts, including absent or unclear review protocols, missed review of charts, and failure to detect or escalate clinically significant concerns shown by chart information.

What is not included

Excludes failures to perform or record observations where the observation-chart review process is not itself deficient.
Excludes generic clinical-record, staffing, training or communication deficiencies unless they directly impair review of observation charts.
Excludes failures of condition-specific systems such as NEWS operation, CTG review or neurological observations when that named system is the more specific supported concern.
Excludes failures to act after observation-chart concerns have been reliably identified and escalated.

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

Reports about this concern sent to each recipient.

Coventry and Warwickshire Partnership NHS Trust1

Devon Partnership NHS Trust1

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1

Langdon Hospital1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

2 Dec2023
Plymouth, Torbay and South Devon
Concerns raised2
1. Lack of clarity over the timing of observation chart checks
2. Lack of clarity over responsibility for checking observation charts
This report raised 4 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 1
1. 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.
AI-generated summary

Paul Perrott · 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

Paul Perrott, an inpatient detained under the Mental Health Act, died on 31 July 2020 after attempting to hang himself on Ashcombe Ward. Concerns included inadequate recording of his 15-minute observations, unclear responsibility for checking observation charts, insufficient staff awareness of his recent and historical suicide risk, and a focus on immediate rather than historical and contextual risks.

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 clarity over the timing of observation chart checks
Wider context from the report
“(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”
Source location
Paul Perrott · 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
Lack of clarity over responsibility for checking observation charts
Wider context from the report
“(2) There appeared to be a lack of clarity over who was responsible for checking the observation charts , when they would be checked by staff over the course of a working day and who would regularly feed back to staff if there was a problem in this respect . ”
Source location
Paul Perrott · 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
Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.

Verbatim wording from the response
“An amendment to the Trust therapeutic engagement and observation policy has been requested to state that the nurse in charge of each shift is responsible for ensuring completion of observations on a shift by shift basis and taking immediate action where these are not completed. This will go through ratification in January 2024 and has been discussed with the Director and Deputy Director of Nursing.”

Source location
Response from Devon Partnership NHS Trust
Page 2 · response
Published 19 December 2023
Open published response
25 Apr2017
Coventry
Concerns raised1
1. Failure to detect concerns in completed observation charts
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Joleen Linton · 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

Joleen Linton died on 3 August 2016 in her room on Spencer Ward, Caludon Centre, after being admitted as an informal patient following an overdose of prescribed drugs. She was discovered deceased at 0800 hours after hourly observations, with concerns about the practicality and reliability of observations, inaccurate recording of her position, reluctance to enter patients’ rooms, and a lack of clarity in the relevant policy.

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 detect concerns in completed observation charts
Wider context from the report
“(4) Potential areas of concern, in relation to the completion of the observation chart, were not detected on the night; ”
Source location
Joleen Linton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
2 Feb2016
South Yorkshire (Eastern)
Concerns raised1
1. Lack of protocols for doctors to regularly review and assess observation charts
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Marc Jason Stephen Poole · 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

Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

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 protocols for doctors to regularly review and assess observation charts
Wider context from the report
“(2) PAWS The observation chart was poorly completed. There were occasions where incorrect scoring had been documented understating MJ’s condition at that time. This was a form and source of information said to have been heavily relied upon but no clear protocols for doctors to regularly review and assess. It would seem further training is required to ensure accurate completion of this form and accurate scoring. ”
Source location
Marc Jason Stephen Poole · Prevention of Future Deaths report
Page 2 · concerns
Open source report