Delayed Recognition of Deterioration
Failure to timely recognize, report, and escalate deteriorating patient conditions, leading to delayed intervention.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
99match
Early warning scores to detect deterioration in COVID-19 inpatients
The Royal College of Physicians has highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores. Outcome: The RCP released a statement on its website relating to revised guidance on the use of early warning scores for COVID-19 inpatients. The RCP suggest that all...
Matched on
terms: delayed, deterioration, recognition
HSSIB recommendation
91match
Delayed recognition of acute aortic dissection
Current recommendations for all patients with acute aortic dissection specify immediate measures to control blood pressure and heart rate. Non-specialist hospitals which may dispatch these patients to specialist centres might wish to review their guidance and instructions to staff in this respect. Specialist centres accepting patients with this and other life-threatening conditions could consider developing clear instructions for...
Matched on
terms: delayed, recognition
PFD report
81match
Stephen Palmer
Concerns were raised regarding delays in surgical assessment and recognition of patient deterioration, along with an inappropriate unit transfer. The report also identified suboptimal clinical management, inadequate ward rounds, and a complete failure of the hospital's CT scanning service.
Matched on
terms: deterioration, recognition
HSSIB recommendation
70match
Recognition of the acutely ill infant
It may be beneficial if the research studies recommended by the National Institute for Health and Care Excellence are conducted in primary care and secondary care to determine whether examination or re-examination after a dose of antipyretic (temperature reducing) medication is of benefit in differentiating between children with a serious illness and those with other conditions. The intention...
Matched on
terms: recognition
PFD report
69match
John Dodd
The coroner noted the patient's INR was not checked despite being on Warfarin and having a fall history. Concerns were also raised about an unreported temperature rise to medical staff and a significant delay in A&E assessment leading to a delayed diagnosis.
Matched on
terms: delayed
CQC enforcement action
69match
Conditions Imposed: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission imposed urgent conditions on Shrewsbury and Telford Hospital NHS Trust's registration following inspections of its maternity and emergency departments. Inspections highlighted concerns regarding reduced foetal movements guidelines in maternity services and the treatment and recognition of sepsis in urgent and emergency care. The conditions require the trust to report weekly to CQC on actions...
Matched on
terms: recognition
GIRFT recommendation
65match
Paediatric Critical Care
Implement strategies to improve early detection of patient deterioration and ensure timely paediatric critical care intervention. a All paediatric providers to implement the national paediatric early warning system when this becomes available. b Every L3 provider should put in place a system of 24/7 critical care outreach. c L3 providers should monitor rates of ward cardiac arrest, via...
Matched on
terms: deterioration
CQC enforcement action
64match
Conditions Imposed: Portsmouth Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) placed four conditions on the registration of Portsmouth Hospitals NHS Trust following an inspection of emergency services at Queen Alexandra Hospital. CQC found that too many people were waiting too long for attention in the Emergency Department, leading to overcrowding and delayed treatment. The conditions require the trust to make immediate improvements to...
Matched on
terms: delayed
MNSI report
62match
Safety spotlight: Delayed escalation in abnormal CTGs
Safety spotlight on delayed escalation when cardiotocography readings are abnormal.
Matched on
terms: delayed
PFD report
61match
Jude Augustus Gordon
The coroner noted failure to escalate care despite a marked increase in the Early Warning Score (SHEWS) and miscalculations. Concerns included the absence of a national, standardised Early Warning Score system and automatic alerts for deteriorating patients.
Matched on
classifier match
PFD report
61match
Selina Broadhurst
The coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
Matched on
terms: delayed
PFD report
61match
David Mountain
The coroner raised concerns that risks of bleeding and vascular damage after pacemaker insertion were not fully investigated despite the patient developing chest pain. An echocardiogram showing a bleed was significantly delayed and its results were not available before the patient's death.
Matched on
terms: delayed
PFD report
61match
Philip Smith
Inadequate and incomplete nursing and medical records were identified regarding patient observations, medication administration, and an incident. A junior doctor declined a senior medical review despite a senior nurse's concerns about patient deterioration.
Matched on
terms: deterioration
HSSIB recommendation
61match
Patient care in temporary care environments
Does your organisation have a way of displaying clinical information and observations of patients in a temporary care environment to all relevant staff, so that trends or deterioration in a patient’s condition can be identified?
Matched on
terms: deterioration
HSSIB recommendation
61match
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions?
Matched on
terms: deterioration
CQC action
61match
The Tunbridge Wells Hospital at Pembury
The service must ensure clinical observations, screening and testing are carried out in a timely way, reviewed, and any deterioration escalated.
Matched on
terms: deterioration
CQC action
61match
Salford Royal Hospital
This service should ensure tools to identify patients at risk of deterioration are used in an accurate and timely manner by staff.
Matched on
terms: deterioration
CQC action
61match
Rochdale Infirmary
This service should ensure tools to identify patients at risk of deterioration are used in an accurate and timely manner by staff.
Matched on
terms: deterioration
PHSO casework decision
60match
P-001111 - Gateshead Health NHS Foundation Trust
Mr T complained ED staff inadequately investigated his dislocated toe and orthopaedic care was severely delayed for a year, causing deterioration, infection, and toe amputation.
Matched on
terms: delayed, deterioration
IMB annual report
59match
Dartmoor (2024)
The report for HMP Dartmoor covers a year dominated by uncertainty and eventual temporary closure due to elevated Radon gas levels, leading to extensive prisoner decanting. While initial safety metrics remained low and in-cell phones improved wellbeing, the period was marked by delayed decision-making from HMPPS, significant estate deterioration, and challenges in maintaining a consistent regime and purposeful...
Matched on
terms: delayed, deterioration
PFD report
57match
Caroline Lee
The coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
Matched on
terms: recognition
PFD report
57match
Ashley Ponsonby
The coroner identified a lack of staff training in managing risks from illicit substance use on wards with dual diagnosis patients. Concerns were also raised about the failure to use incident reporting systems for drug supply/consumption, and the absence of a clear policy between the Mental Health Trust and Police regarding illegal activity.
Matched on
classifier match
PFD report
57match
Kirsty Pritchard
Communication issues meant post-discharge patient contacts indicating worsening symptoms were not reported to the inpatient Consultant for timely self-harm risk assessment. There were also deficiencies in systems for quickly locating patients identified as having an immediate risk of self-harm.
Matched on
classifier match
PFD report
57match
Mark Hudson
The coroner raised concerns that urgent requests for specialist care within the CICU department may be delayed or unanswered. This is due to procedures for CICU staff requesting assistance via the Hospital Switchboard being insufficiently robust.
Matched on
terms: delayed
PFD report
57match
Freda Owens
The coroner noted insufficient quality in information gathering and exchange among medical professionals, including an inadequate examination by a District Nurse and a lack of communication between hospital teams, which delayed specialist assessment.
Matched on
terms: delayed
HSSIB recommendation
57match
Unplanned delayed removal of ureteric stents
The National Institute for Health and Care Excellence guidance for the management of urinary tract infections does not include ureteric stents as a cause of urinary symptoms which could mimic a urinary tract infection. It may be beneficial for this potential complication to be considered in the next review of this and other clinical practice guidance.
Matched on
terms: delayed
HSSIB recommendation
57match
Recognising and responding to critically unwell patients
NHS England/NHS Improvement should expand the remit of the Cross-System Sepsis Programme Board to include physical patient deterioration, involving additional stakeholders as required. HSIB makes the following safety observations Observations: NEWS2 is not intended to be a stand-alone tool. Instead, it is intended to be combined with other relevant charts, clinical investigation results and notes together with clinical...
Matched on
terms: deterioration
CQC action
57match
The York Hospital
The service must ensure the service improves compliance in sepsis screening, especially for patients receiving antibiotics within an hour. They must also ensure ED medical staff improve their overall training compliance rate in sepsis screening and all ED staff complete screening for patients at risk of sepsis (to better recognise and respond to warning signs of deterioration).
Matched on
terms: deterioration
CQC action
57match
Scarborough Hospital
The service must ensure the service improves compliance in sepsis screening, especially for patients receiving antibiotics within an hour. They must also ensure ED medical staff improve their overall training compliance rate in sepsis screening and all ED staff complete screening for patients at risk of sepsis (to better recognise and respond to warning signs of deterioration).
Matched on
terms: deterioration
CQC action
57match
Royal Hallamshire Hospital
The trust must implement an effective system to ensure all patients waiting to be admitted to the department from the ambulance queue are monitored for signs of deterioration.
Matched on
terms: deterioration
PHSO casework decision
57match
P-003595 - North Cumbria Integrated Care NHS Foundation Trust
Mr A complained North Cumbria Integrated Care NHS Foundation Trust failed to quickly identify his mother's serious condition in ED, delayed moving her to critical care, and lost blood tests, impacting her cognitive function.
Matched on
terms: delayed
PHSO casework decision
57match
P-004243 - The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
Mrs B complained her father's care was poor, citing delayed doctor review after a fall, neglected catheterisation, and slow medical intervention, contributing to his death.
Matched on
terms: delayed
CQC enforcement action
57match
Criminal Prosecution: The Dudley Group NHS Foundation Trust
The trust pleaded guilty to failing to provide safe care and treatment to two patients who died of sepsis-related causes in 2018, Natalie Billingham and Kaysie-Jane Bland. The court identified failings in the recognition and treatment of sepsis.
Matched on
terms: recognition
GIRFT recommendation
56match
Renal Medicine
Mandate clinically-approved AKI patient transfer to a renal centre within 24 hours of the decision by the receiving consultant nephrologist. a) NHS England AKI NSS to include the requirement for regional network working and to issue AKI patient transfer policy requiring transfer within 24 hours. b) Regional renal networks to monitor delayed transfer by means of exception reporting...
Matched on
terms: delayed
PHSO casework decision
56match
P-002652 - Stockport NHS Foundation Trust
Mrs O complained the Trust failed to notice her mother's deteriorating condition and COVID-19 symptoms, delayed testing, and unfairly restricted family visits during her mother's final hours.
Matched on
terms: delayed
PHSO casework decision
56match
P-002805 - East of England Ambulance Service NHS Trust
Mr G complained about multiple missed opportunities to diagnose heart problems, including an unacted-on X-ray and a failed ambulance attendance, leading to a delayed heart failure diagnosis.
Matched on
terms: delayed
PFD report
53match
Barbara White
The coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
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classifier match
PFD report
53match
Edna Elsie Mary Eden
The coroner identified delays in a patient receiving prescribed antibiotics and doctor review, alongside infrequent nursing observations and an incorrect EDOD score that prevented escalation. Communication gaps meant nurses struggled to contact doctors, and junior staff did not escalate significant backlogs or concerns.
Matched on
classifier match
PFD report
53match
Herta Woods
Concerns were raised regarding a lack of early senior review for incorrect fluid charting, which contributed to fluid overload, and a failure to record doctor's visits and act on the patient's NEWS score.
Matched on
classifier match
PFD report
53match
Noel Williams
The coroner noted a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, which was important for assessing the patient's fitness for surgery. This gap in communication could lead to future deaths.
Matched on
classifier match
PFD report
53match
Gary Bradshaw
The coroner noted delays in diagnosis, issues with incomplete blood test reporting, and medication prescribed before test results were known. Concerns also included an insufficient threshold for flagging critical blood-calcium levels, inadequate record-keeping, and apparent gaps in patient escalation to intensive care.
Matched on
classifier match
PFD report
53match
Albert Flynn
Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Matched on
classifier match
PFD report
53match
Joyce Nelson
The coroner identified significant delays in doctor assessment and documentation of X-ray results in the Emergency Department due to staff busyness. There were also considerable delays in imaging result reporting, which nearly led to the discharge of a patient with a multi-fractured pelvis.
Matched on
classifier match
PFD report
53match
Linda Rignall
A change in Linda Rignall's condition, recorded on the NEWS Observation chart, was not reported to a doctor on the Acute Medical Unit nor was she assessed.
Matched on
classifier match
PFD report
53match
Yaser Saleh
The EMIS computer system for GPs only flags patients for review if they are on current regular prescriptions, meaning those with chronic diseases who have stopped treatment are not identified for necessary monitoring. This poses a risk of preventable deaths for patients with conditions like asthma and epilepsy.
Matched on
classifier match
PFD report
53match
Susanna Geraty
Inadequate post-operative fluid balance assessment, monitoring, and recording, alongside insufficient nursing records, were identified. The coroner also noted a failure to recognise the patient's acute illness and respond to family concerns.
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classifier match
Committee recommendation
53match
#10 - Long elective care waiting times pose serious risks to patient health and mortality
We received written evidence that long waiting times can put patients at risk. Evidence from Dr Rob Findlay noted that if it is not known what is wrong with undiagnosed patients then some of them will unexpectedly turn out to have a clinically urgent condition such as cancer.17 The National Institute 12 C&AG’s Report, paras 1.2 and 1.7-1.8...
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classifier match
HSSIB recommendation
53match
Sepsis: a patient with abdominal pain
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Matched on
classifier match
HSSIB recommendation
53match
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Matched on
classifier match
CQC action
53match
Westmorland General Hospital
The service must ensure staff assess the risks to women during and after birth in order to identify women at risk of deterioration.
Matched on
terms: deterioration