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
73match
Stephen Palmer
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.
Matched on
terms: delayed, deterioration
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
Jude Augustus Gordon
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Matched on
terms: delayed
PFD report
69match
Mr Pether
Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Matched on
terms: delayed
PFD report
65match
Linda Rignall
A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Matched on
terms: deterioration
PFD report
65match
Freda Owens
There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.
Matched on
terms: delayed
PFD report
65match
Philip Smith
Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
Matched on
terms: deterioration
CQC action
65match
Kettering General Hospital
The servicemust ensure patients showing signs of deterioration or those at risk of sepsis are reviewed by an appropriate grade clinician and treated in a timely manner in line with Sepsis 6 pathways and trust deteriorating patient policies.
Matched on
terms: deterioration
PFD report
61match
Selina Broadhurst
Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Matched on
terms: delayed
PFD report
61match
Mark Hudson
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Matched on
terms: delayed
PFD report
61match
David Mountain
Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.
Matched on
terms: delayed
PFD report
61match
Lana-Liza Chervonenko
High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Matched on
terms: delayed
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
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
Keward Guy Domonic Harding
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Matched on
terms: delayed
PFD report
57match
Caroline Lee
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
Matched on
classifier match
PFD report
57match
Herta Woods
Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.
Matched on
classifier match
PFD report
57match
Ashley Ponsonby
Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.
Matched on
classifier match
PFD report
57match
Albert Flynn
Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
Matched on
classifier match
PFD report
57match
Evelyn Smith
Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
Matched on
terms: recognition
PFD report
57match
Peter Dorney
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Matched on
classifier match
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
Ormskirk District General Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores and newborn risk assessments, record CTG assessments and fresh eyes in order to identify and escalate women, birthing people and babies at risk of deterioration.
Matched on
terms: deterioration
CQC action
57match
Yeovil District Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores and newborn assessment observation and early warning score forms in order to identify and escalate women and birthing people and babies at risk of deterioration.
Matched on
terms: deterioration
CQC action
57match
The James Cook University Hospital
The service must monitor compliance with the calculation, escalation and timely review of MEOWS and take action to improve compliance, and ensure instances of deterioration are identified and actioned promptly
Matched on
terms: deterioration
CQC action
57match
St Helier Hospital and Queen Mary's Hospital for Children
The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk of deterioration.
Matched on
terms: deterioration
CQC action
57match
Royal Berkshire Hospital
The service should ensure staff escalate women and birthing people and babies at risk of deterioration appropriately.
Matched on
terms: deterioration
CQC action
57match
Epsom General Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk 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
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
Edna Elsie Mary Eden
Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Matched on
classifier match
PFD report
53match
Margaret Easterfield
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Matched on
classifier match
PFD report
53match
Noel Williams
The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
Matched on
classifier match
PFD report
53match
John Dodd
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Matched on
classifier match
PFD report
53match
Gary Bradshaw
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Matched on
classifier match
PFD report
53match
Peter White
Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Matched on
classifier match
PFD report
53match
Ella Block
Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.
Matched on
classifier match
PFD report
53match
Kirsty Pritchard
There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.
Matched on
classifier match
PFD report
53match
Sonielia Holmes
The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting advice and review of the patient.
Matched on
classifier match
PFD report
53match
Susanna Geraty
Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.
Matched on
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...
Matched on
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