Missed and inaccurate patient observations
Failure to conduct or accurately record essential patient observations, leading to missed medical reviews and delayed intervention.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Clive Davies
The coroner noted incomplete routine neuro observations and an incorrectly calculated NEWS score. This resulted in a missed medical review for the patient when one was clearly indicated.
Matched on
terms: missed, observation, patient
HSSIB recommendation
87match
Patients at risk of self-harm: continuous observation
Is there a mechanism for regular communication and review of a patient’s risk of self-harm and need for observation?
Matched on
terms: observation, patient
PFD report
81match
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: observation, patient
Inquiry recommendation
78match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration, oxygen saturation and blood pressure.
Matched on
terms: observation, patient
PFD report
77match
John Lansdowne
The coroner identified unclear observation times and a missing observation sheet from medical records, alongside inconsistent understanding among nursing staff regarding patient observation requirements during bathing.
Matched on
terms: observation, patient
PFD report
77match
Gregg O’Reilly
The coroner identified a missed opportunity by multiple medical and nursing teams to refer Mr O'Reilly to critical care, meaning he did not receive optimal care. Furthermore, observation records were missing for a significant period despite two-hourly monitoring being required.
Matched on
terms: missed, observation
PFD report
77match
Jane Robinson
Basic patient observations were repeatedly unrecorded, with no senior review to detect shortfalls or written rationale for observation frequency. Additionally, the coroner noted no reporting system for professionals not meeting accepted standards.
Matched on
terms: observation, patient
PFD report
77match
Elsie Hayward
Medical staff were caring for significantly more patients than a safe ratio, leading to an overstretched team and deficiencies in care. Neuro observations were not performed according to guidance, and poor note-taking caused communication issues between nursing and medical teams.
Matched on
terms: observation, patient
PFD report
77match
Derrick Stanmore
Abnormal patient observations were not recognised as requiring further action, with the coroner suggesting a system similar to an Early Warning Score. Concerns were also raised about the attending nurse not accessing available healthcare records, leading to observations being taken without full clinical context.
Matched on
terms: observation, patient
PFD report
77match
Vinod Kumar
The coroner noted that the triage nurse overly focused on the patient's fall, leading to delayed observations and blood tests for potential infection. Concerns were also raised regarding insufficient observation before patient prioritisation in A&E.
Matched on
terms: observation, patient
PFD report
77match
Matthew Llewellyn-Jones
The coroner noted an ongoing security risk due to a frequently breached "locked door" on the ward and predictable patient observations that are not aligned with best practice. Additionally, a new note-recording system lacks mandatory fields to capture essential information from carers and family upon admission.
Matched on
terms: observation, patient
HSSIB recommendation
74match
Patient care in temporary care environments
Does your organisation have a means of tracking individual patients who are in a temporary care environment to support their clinical observations, understanding their needs and a process by which they document the length of time they have been in the temporary care environment?
Matched on
terms: observation, patient
PFD report
73match
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
terms: observation, patient
PFD report
73match
William Winter
Nursing staff on the Clinical Decisions Unit did not perform a second set of observations or escalate the need for a surgical review, partly due to high patient workload and unfamiliarity with escalation procedures.
Matched on
terms: observation, patient
PFD report
73match
Robert Jones
Insufficient communication among staff regarding the patient's falls history, use of an out-of-date post-falls checklist, and inconsistent or incorrect recording of neurological observations were identified.
Matched on
terms: observation, patient
PFD report
73match
Robin Brett
Nursing staff did not identify a missed steroid dose, and there is no system, either paper or electronic, to alert medical staff about patients on long-term steroid treatment.
Matched on
terms: missed, patient
PFD report
73match
David Hughes
The report identifies that Level 2 observations were not conducted as prescribed, fluid balance charts were incomplete, and patient bedrooms lacked call bells. Concerns were also raised that staff may not adequately appreciate signs of physical illness.
Matched on
terms: observation, patient
PFD report
73match
Marie Rollason
The coroner raised concerns about a junior doctor's misinterpretation of an abnormal ECG trace and Mrs Rollason's subsequent discharge without further observation, identifying this as a missed opportunity for basic medical care and investigation.
Matched on
terms: missed, observation
PFD report
69match
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
terms: patient
PFD report
69match
Peter Norman Nott
The coroner noted that the care home's procedures for post-fall examination were insufficient, as staff did not perform neurological observations. Concerns were also raised regarding inaccurate information provided to paramedics about the resident's consciousness.
Matched on
terms: inaccurate, observation
PFD report
69match
Sebastian Davies
The coroner notes that hourly night observations did not routinely check if patients had moved or remained immobile, and there was a lack of continuity in staff undertaking observations.
Matched on
terms: observation, patient
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: patient
PFD report
69match
Vivian Hunt
No neurological observations were made between 5am and 1:15pm on 3rd April, despite the patient experiencing two falls, one of which resulted in a facial injury.
Matched on
terms: observation, patient
PFD report
69match
Awa Jeng
Insufficient monitoring and medical review for a high-risk patient led to a failure in following instructions for repeat blood tests and checks. The report also highlights a lack of clear action to address concerns about handover of responsibilities between shifts.
Matched on
terms: patient
PFD report
69match
John Matthews
The report notes that the triage nurse did not see the ambulance patient report form and a locum doctor lacked access to complete computerised patient information. There were also concerns that necessary neurological observations were not instituted and an unnecessary CT scan was performed.
Matched on
terms: observation, patient
PFD report
69match
Evelyn Kennedy
Concerns were raised regarding inadequate patient transfer and incomplete handover from the Acute Medical Unit. There were multiple deficiencies in basic care, including hygiene and pressure area management, incomplete essential monitoring charts, and a failure to escalate elevated NEWS scores to doctors.
Matched on
terms: patient
PFD report
69match
Piotr Kucharz
The coroner noted a lack of consistency and clarity among mental health staff regarding what constitutes an effective patient observation, specifically concerning whether to enter a patient's room, engage verbally, or check the environment, which contrasted with Trust policy.
Matched on
terms: observation, patient
PFD report
69match
Christopher Brand
The hospital observation policy was not consistently followed, with staff failing to adequately monitor a patient and check their well-being. There was also a delay in commencing CPR after the patient was found unresponsive.
Matched on
terms: observation, patient
CQC action
69match
University Hospital Aintree
The trust should ensure that work continues to improve compliance with, and the timely recording of patient observations (NEWS2).
Matched on
terms: observation, patient
CQC enforcement action
69match
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
The CQC inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital in May. Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were poor, records of incidents were missing, and parts of the physical environment were unclean. As a result, CQC...
Matched on
terms: observation, patient
CQC enforcement action
69match
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) carried out unannounced focused inspections of Finchingfield Ward in October and November 2020 due to concerning information regarding safety incidents. Inspectors found that some staff did not follow required actions to maintain patient safety, including inadequate observation practices and issues with record-keeping. CQC served warning notices to the trust to ensure improvements are...
Matched on
terms: observation, patient
MNSI report
66match
Safety spotlight: Incomplete observations generating incorrect early warning scores
Safety spotlight on incomplete clinical observations generating incorrect early warning scores.
Matched on
terms: observation
PFD report
65match
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
terms: observation
PFD report
65match
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.
Matched on
terms: patient
CQC action
65match
The Princess Alexandra Hospital
The trust must ensure that patients receive ongoing observations in line with policy.
Matched on
terms: observation, patient
CQC action
65match
The County Hospital
The provider must ensure it is assessing the risks to the health and safety of patients of receiving care or treatment and doing all that is reasonably practicable to mitigate any such risk through carrying out and documenting regular observations, clinically-led navigation of patients through the department provided by trained and experienced staff, managing patients medicines on time,...
Matched on
terms: observation, patient
CQC action
65match
Salford Royal Hospital
The trust should ensure that patient observations are carried out in a timely manner.
Matched on
terms: observation, patient
CQC action
65match
Rochdale Infirmary
The trust should ensure that patient observations are carried out in a timely manner.
Matched on
terms: observation, patient
CQC action
65match
Northwick Park Hospital
The trust should ensure patients assessed as requiring enhanced observations or one to one care receive care in accordance with their assessed needs at all times.
Matched on
terms: observation, patient
CQC action
65match
North Middlesex University Hospital
The services should strengthen safety monitoring procedures, especially for high-risk patients. They should ensure routine observations are always taken on time, patients who required repositioning to manage pressure ulcers should be repositioned as advised by their care plan.
Matched on
terms: observation, patient
CQC action
65match
Kettering General Hospital
The service should ensure that observation rounds are undertaken in a timely manner to minimise delay in identifying deteriorating patients.
Matched on
terms: observation, patient
PFD report
61match
Stuart Aaron Collins
The coroner noted issues with Mr Collins' initial assessment in A&E, the failure to perform hourly nursing observations, and incomplete nursing documentation. Concerns were also raised about the management and accessibility of hand sanitiser gel.
Matched on
terms: observation
PFD report
61match
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
terms: patient
PFD report
61match
Irshad Ali
The coroner noted missing records for intentional rounding checks and hourly neurological observations. Concerns were raised that consultant-stipulated neurological assessments and physiotherapy were not completed before discharge, alongside communication gaps about discharge readiness.
Matched on
terms: observation
PFD report
61match
Paul Moroney
The coroner noted a lack of oxygen saturation monitoring during the patient's first hospital visit and upon discharge, and that previous oxygen level records were unavailable on re-admission.
Matched on
terms: patient
PFD report
61match
Elsie Raper
The coroner identified a delay in diagnosing a patient's tibia and fibula fractures, which remained undiagnosed for several days despite regular GP and nurse visits, leading to extreme pain for the patient.
Matched on
terms: patient
PFD report
61match
Margaret Gleeson
The coroner noted that weekend on-call staffing levels were insufficient for the workload, potentially impacting patient care, and suggested a review. There were also inaccuracies in MEWS tool scoring, indicating a need for refresher training as its use was not clearly understood.
Matched on
terms: patient
PFD report
61match
Margaret Tuck
The coroner identified the absence of a falls prevention care plan and incomplete post-fall nursing assessments and neurological observations. There were also concerns about unclear nurse responsibility and delayed communication of the fall to the consultant.
Matched on
terms: observation
PFD report
61match
Anthony McManus
Concerns were raised regarding the system of observations, particularly at night, with staff conducting hourly checks at the same time each hour rather than randomly, and some observation charts being completed retrospectively without the checks being performed.
Matched on
terms: observation
Inquiry recommendation
61match
F243 - Recording of routine observations
The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot be done, there needs to be a system whereby ward leaders and named nurses are responsible for ensuring...
Matched on
terms: observation