Missed and inaccurate patient observations
Failure to conduct or accurately record essential patient observations, leading to missed medical reviews and delayed intervention.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
149 PFD reports
8 HSSIB recs
30 CQC actions
10 PPO recs
1 IMB rec
56 PHSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
F243 — Recording of routine observations
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
R15 — CDI patient observations records
Recommendation: 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.
Gov response: Section 4.2 of the Scottish Government's response outlines professional standards for record-keeping. The revised NMC code, which all nurses and midwives must follow, specifically requires them to complete all records accurately and without any falsification, …
Accepted
Prevention of Future Deaths reports(149)— showing 50 strongest matches
John Lansdowne
Concerns: Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
Overdue
Stuart Aaron Collins
Concerns: Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Response (South Tees Hospitals NHS Foundation Trust): The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and …
Overdue
Edna Elsie Mary Eden
Concerns: 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.
Response (Heatherwood Wexham Park Hospital NHS Trust): The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage …
Responded
Herta Woods
Concerns: 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.
Overdue
Peter Norman Nott
Concerns: Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Response (Elizabeth Finn Homes): Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale …
Responded
Natasha Raghoo
Concerns: The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
Sebastian Davies
Concerns: Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Overdue
John Dodd
Concerns: Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Response (The Dudley Group NHS Foundation Trust): The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will …
Responded
William Winter
Concerns: Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Overdue
Gregg O’Reilly
Concerns: The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Response (Barts Health NHS Trust): Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board …
Responded
Ashley Ponsonby
Concerns: 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.
Response (Greater Manchester Police): • Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions. • It is often appropriate and necessary for legal proceedings …
Responded
Vivian Hunt
Concerns: Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Response: The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate.
Responded
Irshad Ali
Concerns: The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
Response (Barts Health NHS Trust): The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological …
Responded
Linda Rignall
Concerns: A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Overdue
Zakariyya Clark
Concerns: Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.
Overdue
Maureen Ellett
Concerns: Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Response (Brighton Sussex University Hospitals NHS Trust): Agreement has been reached with SECAMB that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. The Trust is …
Responded
Peter Dorney
Concerns: Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Response (North Bristol NHS Trust): North Bristol NHS Trust clarified that all new nurses receive mandatory Early Warning Score (EWS) training on induction and that 93% of all nurses have received EWS training. The directorate …
Responded
Awa Jeng
Concerns: A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Response (Barts Health NHS Trust): The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of …
Responded
Philip Smith
Concerns: 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.
Overdue
Robert Jones
Concerns: Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per NICE guidelines.
Response (The Health Centre): The GP practice shared the hospital's action plan with their GPs and will have ongoing discussions with the hospital. The hospital updated its falls policy, implemented falls assessments on admission, …
Response (Northern Devon Healthcare NHS Trust): The Trust's falls policy has been revised to include information relating to the frequency and duration of neurological observations, and published on the Trust's policy website. Targeted training on performing …
Overdue
Susanna Geraty
Concerns: 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.
Response (Surrey Sussex NHS Trust): SASH has introduced mandatory training for newly qualified nurses on fluid balance and has issued a reminder to staff regarding the importance of accurately completing fluid balance charts. A Serious …
Responded
John Matthews
Concerns: Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Response (Stockport NHS Trust): The Trust has formally discussed neurological observation needs in sisters' meetings and safety huddles, shared within the ED Quality Newsletter to all ED staff. To avoid a reoccurrence the Trust …
Responded
Paul Moroney
Concerns: Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.
Response (Tameside Hospital NHS Trust): The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the …
Responded
Jane Robinson
Concerns: Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.
Response (University Hospitals of Leicester NHS Trust): The Trust is implementing a competency assessment for HCAs by the end of October 2015 and moving towards electronic recording of observations with automatic EWS calculation and alerts. Clinical handover …
Responded
Philip Robinson
Concerns: Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.
Response (Doncaster Bassetlaw Hospitals NHS Trust): The Trust completed an "observations project" including documentation of EWS on discharge and implemented a safety brief at shift changes. They are also planning to implement the i-Hospital whiteboard system …
Responded
Elsie Hayward
Concerns: Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.
Response (Cardiff Vale University Health Board): Cardiff Vale University Health Board has already undertaken actions including ward-level board rounds, safety briefings, MDT meetings, disciplinary investigation of a nurse, and staff retraining, following an internal investigation and …
Responded
Robert Payne
Concerns: Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Overdue
Derrick Stanmore
Concerns: A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.
Response (Leicestershire Partnership NHS Trust): An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be …
Responded
Evelyn Kennedy
Concerns: Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.
Response (Brighton and Sussex University Hospitals NHS Trust): The Trust has been undertaking work, including improved consultant cover, a working group to address practices and documentation, developing specialist areas, improving signage, improving information handover, and increased monitoring of …
Responded
Parv Patel
Concerns: The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of sepsis, and may distract doctors from the fact that a child is seriously ill despite a low score.
Response: The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising …
Responded
Piotr Kucharz
Concerns: Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or engage. This systemic ambiguity puts vulnerable patients at risk due to inadequate monitoring.
Response: The Trust is planning an external review of its new clinical risk assessment tool and policy in April 2016. A revised observation policy and procedure will be implemented by 31 …
Responded
Shalini Ganesh-Ram
Concerns: The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a CT scan and a surgical consult was not sought until four days post operation, suggesting suboptimal care due to issues within the system.
Overdue
Robin Brett
Concerns: A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Overdue
Leslie Murray
Concerns: Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Overdue
David Hughes
Concerns: Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.
Response (David Hughes): The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and …
Responded
Marie Rollason
Concerns: The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.
Response (Royal Wolverhampton NHS Trust): The Royal Wolverhampton NHS Trust confirms that clinical staff in the Emergency Department receive regular training in the identification and treatment of pulmonary embolism. A training session on venous thromboembolism …
Responded
Elsie Raper
Concerns: A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Response (elsie Raper): The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion …
Response (Four Seasons Health Care): Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate …
Responded
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and …
Responded
Christopher Brand
Concerns: Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.
Response (West London Mental Health NHS Trust): West London Mental Health Trust has implemented monthly checks of observation windows on each ward, and staff have undertaken mandatory training in observation and engagement skills. They are commissioning Immediate …
Responded
Constance Pridmore
Concerns: Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.
Response (University Hospitals of Morecambe Bay NHS Trust): The Trust has undertaken several actions to address radiology reporting delays, including offering overtime to consultants, supporting undergraduate radiographer training, maximizing advanced practitioner skills, employing locums, introducing advice and guidance …
Response (Department of Health): The Department of Health is increasing clinical radiology training posts by 32 in 2016 and is reviewing specialty intakes from 2017 onwards, taking into account the Urgent and Emergency Care …
Responded
Margaret Gleeson
Concerns: Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Response (Wrighton Wigan and Leigh NHS Trust): The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, …
Responded
Margaret Tuck
Concerns: Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Response (Barths Health NHS Trust): Barts Health NHS Trust has re-instructed staff on falls risk assessments and care plans, clarified nursing responsibilities, reinforced post-falls procedures, and implemented measures to improve communication between medical teams. They …
Responded
Vinod Kumar
Concerns: Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.
Overdue
Matthew Llewellyn-Jones
Concerns: Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.
Response (Devon Partnership NHS Trust): Devon Partnership NHS Trust has locked the doors at the Cedars since the inquest and notified entrances that the door is locked; patients are informed on admission, and LED signs …
Responded
Nihad Ousta
Concerns: There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.
Overdue
Alfred Grimshaw
Concerns: A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.
Response (East Lancasshire Hospitals NHS Trust): The Trust has strengthened communication processes for complex frail patient discharges, with emphasis on the Multidisciplinary Team and improved information transfer between primary and secondary care. The case has been …
Responded
Anthony McManus
Concerns: The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
Overdue
Robert Entenman
Concerns: Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a blocked endotracheal tube, compromising patient care.
Response (London Bridge Hospital): London Bridge Hospital implemented several changes including introduction of bedside monitoring and nursing observations policy, the use of SBAR and DOPES handover techniques, and Human Factors Training. They have also …
Response (NMC): The NMC acknowledges the concerns and states that they are currently investigating the matter in accordance with their statutory functions and will provide a further update in due course.
Response (CQC): The CQC details findings from a 2013 inspection where the hospital met standards for staff training and incident reporting. The hospital introduced a critical care daily safety briefing sheet in …
Overdue
Beryl Farmer
Concerns: A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.
Response (Sandwell and West Birmingham Hospitals NHS Trust): The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face …
Overdue
Clive Davies
Concerns: Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
Overdue
HSSIB safety recommendations(8)
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 …
Learning Prompt
Detection of jaundice in newborn babies
It may be beneficial to develop a national standardised Early Warning System track and trigger observation chart for use in neonatal unit settings.
Safety Observation
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?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a physical healthcare hospital policy for the care of patients with mental health needs which includes continuous observation?
Learning Prompt
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?
Learning Prompt
Patient care in temporary care environments
Has your organisation nominated and assigned an individual healthcare professional to oversee temporary care environments, who is responsible for managing the completion of regular patient observations, escalating concerns, and standing back and providing leadership and supervision without being involved in …
Learning Prompt
Recognising and responding to critically unwell patients
It is recommended that the Royal College of Physicians NEWS advisory group continues to evaluate the implementation and use of NEWS2, including but not limited to: The use of NEWS2 in practice, in particular the consistency of recording, the consistency …
Safety Recommendation
Recognition of the acutely ill infant
It may be beneficial if NHS England and NHS Improvement’s System-wide Paediatric Observations Tracking (SPOT) Programme considers visual representation of critical information (such as a clinical intervention administered) and the potential impact of these interventions on an infant’s/child’s PEWS.
Safety Observation
CQC inspection actions(30)
William Harvey Hospital
The trust must ensure all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
University Hospital Lewisham
The service should ensure staff complete and document fresh eyes observations in line with national guidance.
Should Do
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.
Must Do
The Queen Elizabeth Hospital
The service must ensure staff escalate and document adverse baby observations.
Must Do
The Queen Elizabeth Hospital
The service must ensure staff complete and document fresh eyes observations in line with national and trust guidance.
Must Do
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, …
Must Do
Royal Shrewsbury Hospital
The service should consider how it introduces a system to ensure the correct use of fluid balance charts.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Queen Elizabeth Hospital
The services should ensure staff complete and document fresh eyes observations in line with national guidance.
Should Do
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.
Must Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Liverpool Women's Hospital
The trust must ensure that staff complete and record full sets of observations in the intrapartum period and effectively monitor for deterioration.
Must Do
Leighton Hospital
The service should ensure it continues to monitor staff compliance with completing and escalating baby early warning scores so that all babies are risk categorised at birth.
Should Do
Kettering General Hospital
The service should ensure that observation rounds are undertaken in a timely manner to minimise delay in identifying deteriorating patients.
Should Do
Kettering General Hospital
The servicemust ensure children and young people have their observation taken as per risk scoring and clinical condition.
Must Do
Kettering General Hospital
The servicemust ensure patient observations are completed in a timely manner in line with National Early Warning Score frequency rules to ensure deteriorating patients can be quickly identified and escalated.
Must Do
Kettering General Hospital
The servicemust ensure that where a patient requires fluid balance monitoring this is effectively implemented.
Must Do
Doncaster Royal Infirmary
The trust should ensure staff fully and accurately complete patients’ fluid balance charts.
Should Do
Whiston Hospital
The serviceshouldcontinuetomonitorandtakeactiontoensurebabyobservationsarecompletedinlinewithnationalandtrustguidance.
Should Do
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.
Must Do
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
Must Do
St Helier Hospital and Queen Mary's Hospital for Children
The service should ensure ‘fresheyes’ checks of cardiotocography (fetal heart rate) monitoring are carried out hourly.
Should Do
Queen Alexandra Hospital
The service should ensure staff complete and document fresh eyes and fresh ears observations in line with national guidance.
Should Do
Epsom General Hospital
The service should ensure ‘fresheyes’ check of cardiotocography (fetal heart rate) monitoring are carried out hourly.
Should Do
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.
Must Do
William Harvey Hospital
The trust must ensure that all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Liverpool Women's Hospital
The trust must ensure that clinical decision making in relation to the frequency of observations is recorded.
Must Do
PPO death in custody recommendations(10)
The Head of Healthcare
The Head of Healthcare should ensure that when healthcare staff complete vital observations, they use the NEWS2 scoring system as a standard procedure.
The Head of Healthcare
The Head of Healthcare should ensure that clinical observations are taken and recorded when a prisoner is unwell.
The Head of Healthcare
The Head of Healthcare should ensure that: when a prisoner needs clinical observations, these are completed; and staff refer prisoners appropriately to the mental health team.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a MUST assessment when a person is weighed and ensure any concerns are escalated with immediate effect.
The clinical regional manager of Oxleas NHS Trust
The clinical regional manager of Oxleas NHS Trust should: provide assurance to NHS England – Southwest in relation to the repeated recommendations made at HMP The Verne regarding use of the NEWS2 tool; provide a timeframe and assurance on when …
The Head of Healthcare
The Head of Healthcare should ensure that the healthcare team adhere to NICE guideline: Suspected cancer: recognition and referral, by escalating changes in a patient’s weight to the GP who can then decide on the most appropriate plan of care.
The Head of Healthcare
The Head of Healthcare should ensure that red flag symptoms are communicated effectively between team members to ensure there is no delay in appropriate examination and onward referral.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff routinely review patients with high blood pressure results.
The Head of Healthcare
The Head of Healthcare should ensure that, when a patient returns from hospital following A&E attendance, they are reviewed and clinical observations, including NEWS2, are taken.
The Head of Healthcare
The Head of Healthcare should ensure that all staff are aware of the normal range for clinical observations, the relevance of finding an abnormal physical observation and action to take when this is noted.
IMB individual recommendations(1)
PHSO casework decisions(56)
P-004078 — Hampshire Hospitals NHS Foundation Trust
Miss G complained about insufficient nursing staff and monitoring of her father, alarms not set, inability to visit before his death or in the mortuary, and inadequate investigation into missing possessions.
NHS in England
Upheld
Sep 2025
P-004140 — Oxford University Hospitals NHS Foundation Trust
Miss A complained about her daughter's inadequate aftercare post-transplant, including insufficient monitoring and placement outside intensive care, leading to cardiac arrest and death.
NHS in England
Oct 2025
P-004170 — A practice in the Boston area
Mrs H complained the Surgery misdiagnosed her husband, Mr J, failing to identify sepsis, perform observations, or send him to hospital, ultimately leading to his death.
NHS in England
Partly Upheld
Oct 2025
P-004312 — Frimley Health NHS Foundation Trust
Miss E complained the Trust failed to electronically record her father's vital observations and did not escalate his care after he passed blood, leading to his death.
NHS in England
Nov 2025
P-001061 — Royal Free London NHS Foundation Trust
Mr E complained ED staff repeatedly failed to diagnose and treat his arm/chest pain, ignoring prior visits and medical history, leading to a preventable heart attack.
NHS in England
Partly Upheld
Apr 2021
P-001068 — Portsmouth Hospitals NHS Trust
Mrs L complained that A&E staff failed to share information about a suspected 'old fracture', misdiagnosed her back injury, gave incorrect advice to mobilise, and provided inadequate pain relief.
NHS in England
Partly Upheld
May 2021
P-001195 — A healthcare provider in the Knowsley area
Mrs R complained her GP misdiagnosed menopausal symptoms instead of a deep-seated infection, causing delayed treatment and distress, and also about poor complaint handling.
NHS in England
Partly Upheld
Jul 2021
P-001588 — A medical practice in the London Borough of …
Mrs C complained the Practice incorrectly diagnosed her and did not call back despite her symptoms suggesting a heart issue, leading to a heart attack.
NHS in England
Sep 2022
P-001568 — A medical practice in the Southampton area
Mr O complained the Practice misdiagnosed his brother with sciatica in April 2021, which he believed led to his death from prostate cancer in September 2021.
NHS in England
Oct 2022
P-001612 — University Hospitals Sussex NHS Foundation Trust
Mrs M complained the Trust failed to monitor and respond to Mr M's constipation, keep him hydrated, and properly investigate his deteriorating condition, contributing to his death.
NHS in England
Partly Upheld
Nov 2022
P-003884 — King's College Hospital NHS Foundation Trust
Miss A complained about the Trust's care for her brother, alleging he wasn't cared for correctly before sepsis and wasn't given enough fluids. She also cited delays in the complaint process.
NHS in England
Jul 2023
P-003824 — Harrogate and District NHS Foundation Trust
Mr A complained the Trust failed to diagnose and treat a back fracture after a fall, and provided conflicting medical opinions, leading to inability to work and anxiety.
NHS in England
Sep 2023
P-002548 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr Y complained his daughter was not adequately monitored or kept on oxygen, and that an attempted cannulation might have contributed to her death.
NHS in England
Not Upheld
Apr 2024
P-002651 — Northumbria Healthcare NHS Foundation Trust
Mr R complained the Trust failed to monitor or escalate his wife's Addison’s disease, leading to her death and denying her recovery opportunity.
NHS in England
Not Upheld
May 2024
P-002700 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr P complained the Trust misdiagnosed Miss G with alcohol-related liver disease, failed to investigate other causes, and provided inappropriate follow-up care, leading to her death.
NHS in England
Jun 2024
P-002728 — A practice in the Gloucestershire area
Miss E complained the Practice failed to check swollen lymph nodes, share blood/urine test results, and refer her to specialists, leading to financial, mental health, and physical suffering.
NHS in England
Jun 2024
P-002742 — A practice in the Lincolnshire area
The Practice allegedly missed opportunities to investigate Mr O's symptoms, delaying cancer diagnosis, and failed to provide face-to-face GP appointments, impacting his health.
NHS in England
Upheld
Jul 2024
P-002763 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss T complained staff failed to hydrate her mother, properly monitor pressure areas, or regulate oxygen levels, which she believes contributed to her mother's deterioration and death.
NHS in England
Partly Upheld
Jul 2024
P-002867 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr X complained a nurse failed to check and assess his wife for over eight hours during the night, believing earlier assessment could have restarted treatment and prolonged her life.
NHS in England
Aug 2024
P-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to properly support and monitor her brother during a Trial Without Catheter (TWOC), and staff delayed acting on dangerous symptoms, leading to his death.
NHS in England
Mar 2025
P-003804 — Warrington and Halton Hospitals NHS Foundation Trust
Mr A complained the Trust failed to monitor his father's post-operative condition and escalate concerns, leading to his death. He also alleged poor communication with his mother.
NHS in England
Aug 2025
P-004029 — King's College Hospital NHS Foundation Trust
Ms X complained nursing staff failed to accurately record her father's observations and were missing, preventing timely escalation to the Critical Care Outreach Team and contributing to his earlier death.
NHS in England
Partly Upheld
Sep 2025
P-004034 — Isle of Wight NHS Trust
Mrs F complained about the Trust's decision to move her father from ICU, his subsequent monitoring, circumstances surrounding his cardiac arrest, and poor communication, believing his death was avoidable.
NHS in England
Sep 2025
P-003963 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs G complained the Trust failed to adequately monitor her mother's condition, perform risk assessments, give timely antibiotics, perform an angiography, assess fall risk, do a timely ABG test, or provide palliative care, leading to her traumatic death.
NHS in England
Partly Upheld
Sep 2025
P-004142 — A practice in the Mid Devon area
Mrs H complained a nurse practitioner failed to properly assess her daughter's breathlessness, leading to her death, and the Practice mishandled the complaint.
NHS in England
Oct 2025
P-004300 — Mid and South Essex NHS Foundation Trust
Miss J complained the Trust failed to monitor her mother's condition, manage pressure sores, and administer antibiotics correctly, causing premature death and suffering.
NHS in England
Nov 2025
P-001299 — A medical practice in the Hertfordshire area
Patient complained his GP misdiagnosed his symptoms after he collapsed, advising him to go home instead of to hospital, leading to a delayed heart attack diagnosis and permanent health issues.
NHS in England
Feb 2022
P-001327 — Wrightington, Wigan and Leigh NHS Foundation Trust
Mrs A complained the Trust failed to adequately investigate her husband's throat and mouth bleeds in March and May 2018, believing this inaction led to his fatal bleed in June.
NHS in England
Mar 2022
P-001322 — Northampton General Hospital NHS Trust
Mrs E complained that Northampton General Hospital NHS Trust misdiagnosed her son's spinal injury, failed to perform an MRI scan, and discharged him without follow-up treatment.
NHS in England
Mar 2022
P-003819 — Northern Care Alliance NHS Group
The Trust failed to manage her husband's nutrition/hydration, delayed medication, and missed sepsis signs, leading to his avoidable death.
NHS in England
Sep 2023
P-002530 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs R complained Trust staff failed to detect fatal ketone levels during routine blood tests, resulting in her son being admitted in a critical condition and requiring intensive care.
NHS in England
Upheld
Apr 2024
P-002698 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mr O complained the Trust failed to diagnose his wife's cancer, declined gallbladder removal, and discharged her without follow-up appointments, allegedly contributing to her death.
NHS in England
Partly Upheld
Jun 2024
P-002718 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complained about an incorrect referral and insufficient investigation by an ANP, and delayed diagnosis/treatment of stomach cancer by the Trust, reducing Mr A's survival chances.
NHS in England
Not Upheld
Jun 2024
P-002712 — Dartford and Gravesham NHS Trust
Mrs O's husband complained the Trust failed to diagnose her condition and provide appropriate care across five admissions, which he believed led to her premature death.
NHS in England
Partly Upheld
Jun 2024
P-002776 — A practice in the Newcastle upon Tyne area
Mrs N complained the Practice provided poor care to her son, O, disregarding her concerns and speaking inappropriately, leading to hospital admissions.
NHS in England
Jun 2024
P-002783 — Calderdale and Huddersfield NHS Foundation Trust
Mrs P complained about her mother's care, citing delayed intravenous steroids, a delayed CT scan, and delayed diagnosis of giant cell arteritis, contributing to her death.
NHS in England
Jul 2024
P-002749 — North West Anglia NHS Foundation Trust
Miss U complained the Trust failed to regularly monitor and control her father's iron levels for years and failed to provide IV albumin during an ascitic drain procedure.
NHS in England
Partly Upheld
Jul 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complained clinicians failed to act on her mother’s high risk of falls in December 2022, leading to serious injuries and her death. She also alleged documentation was falsified.
NHS in England
Sep 2024
P-003135 — Dorset Healthcare University NHS Foundation Trust
A doctor at the OOH Treatment Centre allegedly failed to examine Miss R or take observations, missing an infection and need for A&E, leading to her avoidable death.
NHS in England
Nov 2024
P-003276 — Stockport NHS Foundation Trust
Ms U complained the Trust failed to reduce her mother's stroke risk, delayed diagnosing her stroke, and delayed diagnosing a bowel obstruction, leading to increased suffering and death.
NHS in England
Partly Upheld
Jan 2025
P-003291 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs T complained the Trust wrongly gave and refused to remove a stent, failed to act on poor NEWS scores, did not inform her family of her husband's worsening condition, and provided poor nursing care.
NHS in England
Partly Upheld
Jan 2025
P-003420 — Mid Yorkshire Teaching NHS Trust
Care for Miss Y's father was allegedly poor, including lack of observation, delayed treatment, and inadequate communication of his deteriorating condition, which Miss Y believes contributed to his death.
NHS in England
Upheld
Mar 2025
P-003424 — A practice in the Walsall area
Miss R complained the Practice and Trust delayed diagnosing her sister's cancer, prescribed ineffective antibiotics, poorly communicated diagnosis, and provided poor palliative care.
NHS in England
Partly Upheld
Mar 2025
P-003454 — A practice in the Gloucestershire area
Ms G complained the Practice missed opportunities to diagnose and treat her ongoing infections between June 2021 and July 2023, causing her suffering and pain.
NHS in England
Mar 2025
P-003559 — Cambridge University Hospitals NHS Foundation Trust
Miss G complained the Trust failed to monitor her eye condition and respond to warning signs, resulting in the loss of her right eye and severe distress.
NHS in England
May 2025
P-004475 — A practice in the South Gloucestershire area
Miss X complains the Practice failed to diagnose her daughter's pneumonia and fluid on her lungs in November 2024, despite ongoing symptoms, leading to serious illness.
NHS in England
Not Upheld
Dec 2025
P-004519 — A practice in the North Yorkshire area
Ms C complained the Practice dismissed her breast lump concerns, leading to a delayed breast cancer diagnosis and treatment after being diagnosed through a routine mammogram.
NHS in England
Not Upheld
Dec 2025
P-004547 — University Hospitals Sussex NHS Foundation Trust
Mr B complained about delayed observations, incomplete initial assessment, and delayed sepsis screening and treatment for his mother at the Trust's Emergency Department.
NHS in England
Partly Upheld
Dec 2025
P-001321 — A medical practice in the Norfolk area
Miss E complained the Practice failed to take her injuries seriously, documented inaccurate information, and kept misleading records, causing her extreme stress and loss of trust.
NHS in England
Mar 2022
P-002554 — Hull University Teaching Hospitals NHS Trust
Mr A complained the Trust missed opportunities to diagnose his mother's foot gangrene, which severely impacted her mobility and quality of life. He also complained about the Trust's poor complaint handling.
NHS in England
Apr 2024