PFD report

Peter John White · Prevention of Future Deaths report

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Issued 5 Sep 2014•Milton Keynes

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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Concerns raised3

  1. Failure to ensure qualified checking and interpretation of Early Warning Observation Chart observations
    Part of recurring concern: Unreliable clinical Early Warning Score systems for deteriorationPart of recurring concern: Unreliable escalation of abnormal clinical observations
  2. Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care
    Part of recurring concern: Failure to take timely escalation action when safety thresholds are breachedPart of recurring concern: Unreliable clinical Early Warning Score systems for deteriorationPart of recurring concern: Unreliable escalation of abnormal clinical observations
  3. Lack of regular audit of Early Warning Observation Chart completion, interpretation and action
    Part of recurring concern: Failure of care and safety auditing to identify deficienciesPart of recurring concern: Failure to assure reliable patient observationsPart of recurring concern: Unreliable clinical Early Warning Score systems for deterioration
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 clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure qualified checking and interpretation of Early Warning Observation Chart observations

Wider context from the report

“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”

Is this part of a recurring concern?

Yes — Unreliable clinical Early Warning Score systems for deterioration; Unreliable escalation of abnormal clinical observations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care

Wider context from the report

“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”

Is this part of a recurring concern?

Yes — Failure to take timely escalation action when safety thresholds are breached; Unreliable clinical Early Warning Score systems for deterioration; Unreliable escalation of abnormal clinical observations.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of regular audit of Early Warning Observation Chart completion, interpretation and action

Wider context from the report

“(1)Evidence was given to me that observation of patients are conducted throughout the Hospital using an Early Warning Observation Chart. The observations are often recorded by unqualified Health Care Assistants but the recordings should be checked and interpreted by a qualified nurse. A trigger score is given for each set of observations; one trigger should result in a review by a senior nurse and an increase in the frequency of observations, two triggers requires a review by a doctor and three triggers a review by a specialist registrar. The chart is a tool to ensure that there is an escalation of care to an appropriate level. (2) In the case of Mr. White the EWS chart was not completed correctly, triggers were ignored and none of the observations were checked by a qualified member of staff. The evidence of Dr. ████████ an independent expert was “This resulted in lost opportunities to reassess Mr. White and put in place the necessary resuscitative measures. (3) I was also told that there is no regular audit system in place to ensure that the charts are correctly completed, interpreted and acted upon. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies; Failure to assure reliable patient observations; Unreliable clinical Early Warning Score systems for deterioration.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026