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 14 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
152 PFD reports
8 HSSIB recs
117 CQC actions
10 PPO recs
1 IMB rec
1 DHR rec
56 PHSO decisions
6 CQC enforcement actions
2 MNSI reports
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: Accepted. In the initial Government response to The Inquiry, Patients First and Foremost, the Department of Health gave strong support to supervisory roles for Ward Managers (including Sister, Charge Nurse and Team Leader) in delivering …
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: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
Prevention of Future Deaths reports(152)— showing 50 strongest matches
John Lansdowne
Concerns: 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.
Overdue
Stuart Aaron Collins
Concerns: 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.
Response (South Tees Hospitals NHS Foundation Trust): • The Accident and Emergency Department introduced a "Patient Status or Glance Board" to note patients requiring regular observations and specific investigations. • Hand sanitiser dispensers were removed from the … (AI summary)
Responded
Edna Elsie Mary Eden
Concerns: 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.
Response (Heatherwood Wexham Park Hospital NHS Trust): • The Trust introduced Policy TPP 231 in August 2013, which includes requirements for verifying EDOD score calculations and strengthens the use of the SBAR communication tool. • A new … (AI summary)
Responded
Herta Woods
Concerns: 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.
Overdue
Peter Norman Nott
Concerns: 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.
Response (Elizabeth Finn Homes): • The organisation stated it would cascade updated procedures for neurological observations and head injury care to all clinical staff by April 1, 2014. • The organisation stated it would … (AI summary)
Responded
Natasha Raghoo
Concerns: The coroner noted insufficient staff training in resuscitation, sporadic physical observations which ceased prematurely, and the lack of an electrocardiogram despite clinical need. Inconsistent staff handovers and unclear communication policies were also identified.
Response (Partnership in Care): • A programme of monthly emergency incident drills was implemented, and a company-wide training programme for Immediate Life Support, including defibrillator use, was delivered to qualified nurses and doctors. • … (AI summary)
Overdue
Sebastian Davies
Concerns: 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.
Overdue
John Dodd
Concerns: 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.
Response (The Dudley Group NHS Foundation Trust): • A written guideline will be developed for routine INR checks for patients on anticoagulants presenting after a fall. • An audit process will be developed to review the appropriate … (AI summary)
Responded
William Winter
Concerns: 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.
Overdue
Gregg O’Reilly
Concerns: 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.
Response (Barts Health NHS Trust): • The Trust stated it would recruit a Band 7 Sister for the relevant ward. • The Trust committed to developing formal guidelines for Critical Care Outreach Team medical reviews. … (AI summary)
Responded
Ashley Ponsonby
Concerns: 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.
Response (Greater Manchester Police): • Greater Manchester Police (GMP) developed a comprehensive Mental Ill Health and Learning Disabilities Policy in April 2013 to clarify police engagement with other agencies on mental health matters. • … (AI summary)
Responded
Vivian Hunt
Concerns: 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.
Response: • A corrective Action Plan for Improvement was developed. • Actions regarding compliance with neurological investigations post head injury have been taken forward by the Mental Health Directorate. • Actions … (AI summary)
Responded
Irshad Ali
Concerns: 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.
Response (Barts Health NHS Trust): • The Trust stated it would implement monthly senior nursing audits and spot checks for the integrity of patient note filing and compliance with intentional rounding. • Staff have been … (AI summary)
Responded
Linda Rignall
Concerns: 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.
Overdue
Zakariyya Clark
Concerns: The coroner raises concerns regarding significant deficiencies in the examination, assessment, and documentation of observations, Glasgow Coma Score, and haematoma details for babies and children in the Accident and Emergency department.
Overdue
Maureen Ellett
Concerns: Initial A&E paperwork was incomplete, as blood pressure and Glasgow Coma scales were not recorded on the front sheet.
Response (Brighton Sussex University Hospitals NHS Trust): • Agreement was reached with the South East Coast Ambulance NHS Foundation Trust for National Early Warning Scores (NEWS) to be calculated, which the triage nurse will note upon patient … (AI summary)
Responded
Peter Dorney
Concerns: The coroner identified that the Early Warning Score (EWS) protocol was not followed and EWS training for nurses is not mandatory, despite its importance for patient well-being.
Response (North Bristol NHS Trust): • The Trust stated that all new nurses receive mandatory Early Warning Score (EWS) training during induction. • Following the Regulation 28 report, the Trust reviewed staff training records and … (AI summary)
Responded
Awa Jeng
Concerns: 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.
Response (Barts Health NHS Trust): • A section for signing and dating has been added to the handover sheet for audit and transparency purposes. • Instructions have been issued to junior doctors in orthopaedics and … (AI summary)
Responded
Philip Smith
Concerns: 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.
Overdue
Robert Jones
Concerns: 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.
Response (The Health Centre): • The Health Centre stated it would share the hospital's Action Plan with all GP colleagues in its practice. • The Health Centre stated it would have ongoing discussions with … (AI summary)
Response (Northern Devon Healthcare NHS Trust): • The Trust revised its falls policy to include recommended frequency and duration of neurological observations based on NICE guidance and a new post-falls checklist. • The Trust's bedside handover … (AI summary)
Overdue
Susanna Geraty
Concerns: 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.
Response (Surrey Sussex NHS Trust): • The Trust implemented new Early Warning Score (EWS) paperwork in January 2014 and provides regular training, including SBAR communication guides and pads introduced to wards in January 2015. • … (AI summary)
Responded
John Matthews
Concerns: 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.
Response (Stockport NHS Trust): • The Trust amended its induction training pack in November 2014 to provide clear instructions on accessing electronic ambulance documents. • The ED Matron re-iterated to nursing staff the importance … (AI summary)
Responded
Paul Moroney
Concerns: 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.
Response (Tameside Hospital NHS Trust): • The Trust stated that oxygen saturations were monitored and recorded during the patient's initial hospital visit. • The Trust provided specific oxygen saturation readings and times from the patient's … (AI summary)
Responded
Jane Robinson
Concerns: 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.
Response (University Hospitals of Leicester NHS Trust): • Work has begun to introduce a competency assessment for Health Care Assistants, with completion expected by October 2015. • The Trust is implementing an electronic system for recording patient … (AI summary)
Responded
Philip Robinson
Concerns: Unsatisfactory safe discharge and inconsistent Early Warning Score (EWS) recording and communication were noted. The coroner also highlighted a lack of clear ECG guidelines for acute breathlessness and the extreme risk of absent senior medical review.
Response (Doncaster Bassetlaw Hospitals NHS Trust): • The Trust implemented an "observations project" and embedded safety briefs to improve the documentation and communication of Early Warning Scores (EWS) on discharge and between staff. • The i-Hospital … (AI summary)
Responded
Elsie Hayward
Concerns: 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.
Response (Cardiff Vale University Health Board): • The Clinical Director for Internal Medicine worked with junior doctors to agree a process for covering short-term staff absences. • The 'core-care plan' and 'real time documentation' have been … (AI summary)
Responded
Robert Payne
Concerns: Repeated falls occurred despite the deceased being identified as high risk, with one fall necessitating further surgery. A ward transfer also occurred at 1 am without a transfer document, preceding an unwitnessed fall.
Overdue
Derrick Stanmore
Concerns: 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.
Response (Leicestershire Partnership NHS Trust): • An adapted Track and Trigger system will be introduced, with staff training anticipated by October 2015. • A review confirmed that all staff are able to access clinical information … (AI summary)
Responded
Evelyn Kennedy
Concerns: 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.
Response (Brighton and Sussex University Hospitals NHS Trust): • The Trust increased permanent staffing levels in the Acute Medical Unit, including a matron, a senior nurse, and a new support assistant role. • A practice educator was appointed … (AI summary)
Responded
Parv Patel
Concerns: The coroner noted that PEWS scores do not reflect current research into child illness and may distract doctors from recognising serious illness in children with low scores.
Response: • NHS England is continuing to work towards developing a consensus view on a paediatric early warning system. • NHS England, with the Royal College of Paediatrics and Child Health, … (AI summary)
Responded
Piotr Kucharz
Concerns: 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.
Response: • The Trust replaced its previous risk assessment tool with new standard and enhanced tools in March 2015 and has provided training to staff on their use. • An internal … (AI summary)
Responded
Shalini Ganesh-Ram
Concerns: The coroner identified delays in diagnosing a caecum perforation, citing issues with the timely prompting and performance of CT scans, and obstetric registrars not seeking surgical consultation. Concerns also included the inappropriate use of the modified obstetric early warning score tool for sepsis identification.
Overdue
Robin Brett
Concerns: 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.
Overdue
Leslie Murray
Concerns: Insufficient staff cover for 1:1 patient care on Holdsworth ward, and likely other wards, leads to preventable falls and care deficiencies that may contribute to death.
Overdue
David Hughes
Concerns: 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.
Response (David Hughes): • A new Therapeutic Observation Policy was implemented in 2015, including staff competency-based training and checks, and disciplinary action was taken against staff involved in the incident. • The service … (AI summary)
Responded
Marie Rollason
Concerns: 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.
Response (Royal Wolverhampton NHS Trust): • The Emergency Department provides regular training on the identification and treatment of pulmonary embolism. • A training session on venous thromboembolism was recently delivered within the Emergency Department. • … (AI summary)
Responded
Elsie Raper
Concerns: 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.
Response (elsie Raper): • The organisation stated that falls in elderly, frail individuals should prompt investigations and prompt referral for assessment, including x-rays, without delay. • The organisation indicated that care plans should … (AI summary)
Response (Four Seasons Health Care): • Implemented 24-hour falls observation charts to monitor residents more closely after a fall. • Compiled a list of residents with osteoporosis and updated their care plans to incorporate details … (AI summary)
Responded
Lincoln Brady
Concerns: The coroner noted that non-correlating examination results were not further investigated with an ultrasound, leading to an undiagnosed breech presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): • The Trust implemented 'Lincoln's Rule' in January 2015, establishing a low threshold for considering presentation scans and highlighting red flags for further investigation. • Policies and training for managing … (AI summary)
Responded
Christopher Brand
Concerns: 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.
Response (West London Mental Health NHS Trust): • Monthly checks of observation windows were introduced, alongside unannounced audits of observation practice. • Standard operating procedures were implemented for nurses in charge, requiring them to confirm patient wellbeing … (AI summary)
Responded
Constance Pridmore
Concerns: The coroner noted that X-rays on admission are not immediately reviewed by a radiologist, leading to delays in identifying injuries due to a national shortage of radiologists. This practice creates a foreseeable risk of further deaths and fails to meet national targets for urgent X-ray reporting.
Response (University Hospitals of Morecambe Bay NHS Trust): • The Trust records the risk associated with reporting capacity on its corporate risk register, which is reviewed quarterly. • The Trust has appointed three radiologists in the past 12 … (AI summary)
Response (Department of Health): • Health Education England is taking forward a programme of action to support diagnostics specialisms, prioritising Clinical Radiology consultants. • Training posts for Clinical Radiology will increase by 32 in … (AI summary)
Responded
Margaret Gleeson
Concerns: 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.
Response (Wrighton Wigan and Leigh NHS Trust): • The Surgical Division allocated a middle grade surgeon to conduct weekend ward rounds for elective patients, and the Trust is recruiting two clinical fellows. • The Trust provided extensive … (AI summary)
Responded
Margaret Tuck
Concerns: 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.
Response (Barths Health NHS Trust): • The Trust implemented new falls assessment paperwork, introduced high-risk wristbands, and now nurses high-risk patients in bays allowing direct observation. • Staff allocation was revised to ensure each patient … (AI summary)
Responded
Vinod Kumar
Concerns: 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.
Overdue
Matthew Llewellyn-Jones
Concerns: 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.
Response (Devon Partnership NHS Trust): • The Trust reviewed its Entry and Exit Policy, recommending locked doors on all inpatient units, and confirmed that doors at the Cedars ward have been locked since the inquest, … (AI summary)
Responded
Nihad Ousta
Concerns: The coroner noted the absence of a protocol or written guidance for managing head injuries, including specified frequencies and ranges for general and neurological observations.
Overdue
Alfred Grimshaw
Concerns: Concerns were raised regarding the initial failure to X-ray a hip fracture after an unwitnessed fall, and that a visible fracture on a subsequent X-ray was not reported. Further issues included an unfulfilled physiotherapy review prior to discharge.
Response (East Lancasshire Hospitals NHS Trust): • Specific measures were implemented to reduce the risk of further errors in X-ray reporting. • Processes for communication regarding discharges of complex frail patients were strengthened, and developments occurred … (AI summary)
Responded
Anthony McManus
Concerns: 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.
Overdue
Robert Entenman
Concerns: The coroner noted nurses did not observe a humidifier had been turned off during checks and handovers, and there were delays in identifying and replacing a blocked endotracheal tube. The humidifier machine also lacked an alarm to indicate when it was off.
Response (NMC): • The NMC is investigating the matter and considering the concerns in accordance with its statutory functions. (AI summary)
Response (CQC): • The CQC requested and received the Hospital's Root Cause Analysis (RCA) document. • The CQC conducted an inspection in September 2016 and was satisfied that critical care staff were … (AI summary)
Overdue
Beryl Farmer
Concerns: The coroner identified the absence of a falls risk assessment for Mrs Farmer and a lack of justification for her transfer to an unmonitored bay. Concerns were also noted regarding insufficient post-fall observations and the omission of a CT head scan despite significant bruising.
Response (Sandwell and West Birmingham Hospitals NHS Trust): • The Trust confirmed that existing policies and procedures for head injuries and inpatient falls had been re-checked by the Medical Director and Chief Nurse and met standards. • The … (AI summary)
Overdue
Clive Davies
Concerns: 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.
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
NCEPOD recommendations(10)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
CQC inspection actions(117)— showing 50 strongest matches
Wythenshawe Hospital
The service should ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ and intermittent auscultation in line with guidance.
Should Do
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
Westmorland General Hospital
The trust must ensure that patients’ pain is effectively managed including that pain scores are re-assessed within 60 minutes as per trust policy.
Must Do
University Hospital Lewisham
The service should ensure staff complete and document fresh eyes observations in line with national guidance.
Should Do
University Hospital Aintree
The trust should ensure that work continues to improve compliance with, and the timely recording of patient observations (NEWS2).
Should Do
The York Hospital
The service must ensure staff do not place patients at higher risks such as those with IV access or allergies in inappropriate environments for their needs and observe them accordingly.
Must 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 Princess Alexandra Hospital
The trust must ensure that patients receive ongoing observations in line with policy.
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
Sunderland Royal Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
Sunderland Royal Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
St Albans City Hospital
The trust should ensure that National Early Warning Scores are recorded for every admission.(Regulation 12).
Should Do
South Tyneside District Hospital
The trust must ensure staff undertake cardiotocographies (CTGs) and ensure this is recorded, assessed, monitored and escalated as appropriate with fresh eyes assessments.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
Salford Royal Hospital
The trust should ensure that patient observations are carried out in a timely manner.
Should Do
Salford Royal Hospital
The service should ensure it takes appropriate actions to improve timeliness and compliance for completing risk assessments and intentional rounding observations in line with trust targets.
Should Do
Saint Mary's Hospital
The service must ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ and intermittent auscultation in line with guidance. Regulation 12(1)(2)(a)(b)
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
Royal Preston Hospital
The service should ensure staff carry out newborn observations using track and trigger system in a timely way in line with local guidance.
Should Do
Royal Preston Hospital
The service should continue to monitor the correct recording of NEWS2 observations.
Should Do
Royal Hallamshire Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
Royal Hallamshire Hospital
The trust must ensure staff undertake and record appropriate observation of service users’ health after administering rapid tranquilisation.
Must Do
Rotherham General Hospital
The trust must ensure that staff record completed intentional rounding of all patients in the waiting area.
Must Do
Rochdale Infirmary
The trust should ensure that patient observations are carried out in a timely manner.
Should Do
Rochdale Infirmary
The service should ensure it takes appropriate actions to improve timeliness and compliance for completing risk assessments and intentional rounding observations in line with trust targets.
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
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.
Should Do
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.
Should Do
North Manchester General Hospital
The service must ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ in line with guidance. Regulation 12(1)(2)(a)(b)
Must Do
Northern General Hospital
The trust must ensure staff undertake and appropriately record intentional rounding of all service users and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
Northern General Hospital
The trust must ensure staff undertake and record appropriate observations of service users’ health after administering rapid tranquilisation.
Must Do
Mount Vernon Cancer Centre
The trust should ensure that all observations of vital signs are completed on time.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurestafffullyandaccuratelycompletepatients’fluidbalancecharts.
Should Do
Medway Maritime Hospital
There should be sufficient CTG paper available and accessible to necessary staff at all times to ensure ongoing monitoring of babies when required.
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
Lister Hospital
The trust should ensure that pain scores are recorded and re-assessed.
Should 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
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)
Health investigations(24)
Independent investigation report into the care and treatment of Yusuf — Rec 2
While they did not affect the prompt access to care, the clinical examinations and physiological observations carried out by the paramedics did not fully comply with local or national guidelines. Essential examinations and physiological observations must be completed and documented in the clinical records in line with Joint Royal Colleges …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 2
Different paediatric observation tools (for example, the Paediatric Observation Priority Score (POPS) and Paediatric Early Warning System (PEWS)) were used by different providers across the care pathway. We are aware of the efforts of NHS England, the Royal College of Nursing and the Royal College of Paediatrics and Child Health …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.ii.c
There should be a clear policy for close observation of patients, which reflects standards proposed by the Royal College of Nursing.
north_west
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Six
It is recommended that the Trust further review their observation policy to include supervision of the person conducting observations and changing the format of their observation form to ensure that: Clarity in regard to observation responsibility is added and staff responsible for the agreed tasks are identified and documented on …
london
Independent investigation: Linda Goswell, Cygnet hospital, Bradford (2014) — Rec 11
Cygnet Health Care should ensure the policy on levels of observations is clear and understood by staff, and routinely audit engagement and observation records to ensure full compliance with their policy. This audit performance should be reported to local and corporate clinical governance meetings, and at quality performance meetings with …
north_east_yorkshire
Independent report into the care of patient T: December 2015 — Rec 2
Adherence to the Observation policy with respect to recording of clinical information and formal reviews should be monitored
Hertfordshire Partnership NHS Foundation Trust
east_of_england
Assurance Review: Trust recommendations — Rec 23
Clinical monitoring The Trust should continue to embed good practice and use of: • Venous thromboembolism (VTE) assessment. • Nutrition, hydration and associated food/fluid balance monitoring must be enforced as fundamental standards. Use of the Malnutrition Universal Screening Tool (MUST) should be audited at specified intervals to ensure scoring and …
north_west
Assurance Review: Trust recommendations — Rec 14
Fluid balance monitoring Fluid balance practice should be audited and a programme of high-quality recording put in place for Urology patients.
north_west
An independent mental health homicide investigation into the care and … — Rec 12
AWP should carry out a review of how the assessment and recovery team undertakes and maintains physical health monitoring of patients who have complex mental health and physical health issues.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent external quality assurance review (published November 2019) can … — Rec 3.
The Trust should ensure that MHSOP wards fully comply with the policy on recording observations.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 3.
The Trust should ensure that MHSOP wards fully comply with the policy on recording observations.
north_east_yorkshire
An independent investigation into the care and treatment of two … — Rec 6
The Trust must ensure that observations form part of a patient’s electronic record.
north_east_yorkshire
An independent investigation into the care and treatment of Thomas: … — Rec 1
This case underlines the lack of expectation of residential care home staff to be able to deliver a range of physical health observations that individuals in a normal domestic situation either independently, or with the support of family/carers undertake at home. Objectively Thomas may have benefited from having his temperature, …
north_east_yorkshire
An independent investigation into the care and treatment of Patient … — Rec 11
Cygnet Health Care should ensure the policy on levels of observations is clear and understood by staff, and routinely audit engagement and observation records to ensure full compliance with their policy. This audit performance should be reported to local and corporate clinical governance meetings, and at quality performance meetings with …
north_east_yorkshire
An independent investigation into the care and treatment of mental … — Rec 3
The Trust should ensure that MHSOP wards fully comply with the policy on recording observations.
Tees Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
An independent investigation into the care and treatment of Emily … — Rec 13
TEWV must ensure that the Supportive Observation and Engagement Procedure requires that care plans specify whether to enter the individual’s room if they cannot be observed from the doorway.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 6
TEWV must ensure that decisions about observation levels are clearly recorded and that all interventions are clearly documented.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Michael Green, Nottingham (2005) — Rec R2
The trust should continue to audit compliance with its observation policy and provide evidence of the audit outcomes to its lead commissioners Nottingham City PCT.
midlands
An independent external quality assurance review (published November 2019) can … — Rec 1.
The Trust should assure itself that the findings and observations of patients when admitted to MHSOP wards leads to accurate care planning and appropriate interventions.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 1.
The Trust should assure itself that the findings and observations of patients when admitted to MHSOP wards leads to accurate care planning and appropriate interventions.
north_east_yorkshire
Independent investigation into the care and treatment of Mr I — Rec 7
Commissioners of care and support services should ensure that service providers have an appropriate policy to record welfare checks. The policy should include clarity about the purpose, content and interval of those welfare checks, it should also be clear about the escalation process once the maximum interval has been reached.
Mr I who committed a homicide in April 2012. At the time of the death, Mr I was in receipt of mental health service from Central and North West London NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of mental … — Rec 1
The Trust should assure itself that the findings and observations of patients when admitted to MHSOP wards leads to accurate care planning and appropriate interventions.
Tees Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation: Terry Radford, Mansfield Woodhouse (2019) — Rec Recommendation 5
Within six months the healthcare team should implement a system which ensures that the daily healthcare review for prisoners held in segregation takes into account observations and records made by both prison and healthcare staff and that the review assesses both risk to self and risk to others.
midlands
Independent investigation into the care and treatment of Ms A — Rec 15
The Trust to review the uptake of training relating to risk assessment and management, and clinical observation, for all Mental Health Liaison Team staff to ensure staff are up to date.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent reviews(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
Domestic Homicide Reviews(1)
CQC enforcement actions(6)
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 …
Fulbourn Hospital, Cambridge
Jul 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Greater Manchester Mental Health NHS Foundation Trust. This action followed a focused inspection in April of community-based mental health services for adults of working age. Inspectors found that patients and …
Jun 2022
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) served Essex Partnership University NHS Foundation Trust with a warning notice following an inspection of two acute wards for adults of working age. The inspection raised serious concerns about patient safety, including staff not always …
acute wards for adults of working age
Apr 2023
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 …
inpatient mental health wards
Jan 2021
Conditions Imposed: The Princess Alexandra Hospital NHS Trust
The Care Quality Commission (CQC) placed conditions on The Princess Alexandra Hospital NHS Trust's registration following an inspection in July, August and September. This action was taken due to serious concerns found regarding the lack of monitoring of patients waiting …
Nov 2021
Warning Notice: University Hospitals of Morecambe Bay NHS Foundation Trust
The Care Quality Commission (CQC) issued two formal warning notices to University Hospitals of Morecambe Bay NHS Foundation Trust. Following investigation visits, inspectors found that patients were not always monitored appropriately at the Royal Lancaster Infirmary and Furness General. Additionally, …
Mar 2012
MNSI reports(2)
Safety spotlight: Incomplete observations generating incorrect early warning scores
Safety spotlight on incomplete clinical observations generating incorrect early warning scores.
Themed Review
Mar 2025
Safety spotlight: Delayed escalation in abnormal CTGs
Safety spotlight on delayed escalation when cardiotocography readings are abnormal.
Themed Review
Mar 2026