NEWS score over-reliance
Delayed infection diagnosis due to over-reliance on National Early Warning Score (NEWS) without comprehensive assessment.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
100match
Early warning scores to detect deterioration in COVID-19 inpatients
The Royal College of Physicians has highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores. Outcome: The RCP released a statement on its website relating to revised guidance on the use of early warning scores for COVID-19 inpatients. The RCP suggest that all...
Matched on
terms: news, over, reliance, score
PFD report
85match
Dave Onawelo
The coroner identified inadequate monitoring and delayed medical intervention for a critically ill patient with sickle cell anaemia, which might have prevented a fatal outcome. Concerns also involved emergency department congestion, over-reliance on the NEWS algorithm, and insufficient clinical curiosity.
Matched on
terms: news, over, reliance
PFD report
81match
Frances Gibb
The coroner identified serious deficiencies in the use of the National Early Warning Score (NEWS) system.
Matched on
terms: news, score
HSSIB recommendation
80match
Recognising and responding to critically unwell patients
NHS England/NHS Improvement should expand the remit of the Cross-System Sepsis Programme Board to include physical patient deterioration, involving additional stakeholders as required. HSIB makes the following safety observations Observations: NEWS2 is not intended to be a stand-alone tool. Instead, it is intended to be combined with other relevant charts, clinical investigation results and notes together with clinical...
Matched on
terms: news, over, score
PFD report
77match
Della Calvey
The coroner identified concerns regarding the practice of downgrading NEWS scores for patients with COPD without knowing their baseline oxygen saturation levels, noting this unsafe practice required a more robust approach to clinical assessments.
Matched on
terms: news, score
PFD report
73match
Clive Davies
The coroner noted incomplete routine neuro observations and an incorrectly calculated NEWS score. This resulted in a missed medical review for the patient when one was clearly indicated.
Matched on
terms: news, score
PFD report
69match
Graham Fox
The coroner noted a discrepancy in understanding among nursing staff regarding the mandatory nature of clinical responses based on NEWS scores, with junior staff perceiving discretion. Concerns were also raised about the clinical appropriateness of the common practice of "re-triggering" patients under NEWS.
Matched on
terms: news, score
PFD report
69match
Kay Simmonds
Concerns were raised regarding an incorrect NEWS score calculation by a nurse, which led to a failure to refer the patient to a senior medical practitioner. Additionally, subsequent observations were not performed in line with NEWS requirements.
Matched on
terms: news, score
PFD report
69match
Dhananji Dona
The specialist National Early Warning Score matrix for prenatal women was not used throughout the hospital, and there were no immediate plans to implement it despite its intended use across all hospital departments.
Matched on
terms: score
MNSI report
65match
Safety spotlight: Incomplete observations generating incorrect early warning scores
Safety spotlight on incomplete clinical observations generating incorrect early warning scores.
Matched on
terms: score
HSSIB recommendation
65match
Sepsis: a patient with abdominal pain
New confusion in patients is not consistently accounted for in NEWS2 scores.
Matched on
terms: news, score
PPO recommendation
63match
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff consistently use the National Early Warning Score 2 (NEWS2) to assess prisoners who are unwell and identify any clinical deterioration.
Matched on
terms: news, score
PFD report
61match
Simon Healey
The coroner noted that private hospitals' NEWS policies for critically unwell patients may not align with emergency response guidance due to consultant availability. Also, general ward nursing staff may lack adequate training for complex post-operative care.
Matched on
terms: news
PFD report
61match
Alexander Braund
The coroner identified a lack of a safe system, training, and compliance auditing for using the NEWS2 assessment tool for acutely unwell patients in a secure setting, leading to an inconsistent application and awareness among staff.
Matched on
terms: news
PFD report
57match
Denise Prior
The coroner noted inadequate record-keeping practices at St Richards Hospital regarding the recording and prescription of oxygen levels, and issues with the application or deviation from the NEWS system.
Matched on
terms: news
PFD report
57match
June Parkes
Deficiencies in provision and protocols for urgent and emergency endoscopies and surgery were identified. Concerns also included staff compliance with the NEWS system, record-keeping, and criteria for doctor presence during critical patient transfers.
Matched on
terms: news
PFD report
57match
Alice Gibson-Watt
The coroner raised concerns regarding the identification and escalation of care for acutely physically unwell patients in acute mental health settings. There was insufficient regular monitoring of vital signs, and established observation systems like NEWS were not always followed.
Matched on
terms: news
PFD report
57match
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Matched on
terms: news
PFD report
57match
Tammy Watkins
Concerns were raised regarding the poor quality of acute physical healthcare in mental health settings, including failures to recognise deteriorating patients and delays in escalation for secondary care. The report notes a lack of adherence to the NEWS2 policy and confusion among staff regarding emergency medical call procedures.
Matched on
terms: news
PFD report
49match
Carla London
The coroner noted a need to consider NICE guidance on late-onset sepsis in babies under 1500g and for further research into infection monitoring systems like HeRO.
Matched on
classifier match
CQC action
48match
Dorset County Hospital
TheserviceshouldensureMEOWSandNEWSchartsarecompletedcorrectlyandusedtoeffectivelyidentifyand escalatedeterioratingpatients.
Matched on
terms: news
PPO recommendation
47match
Clinical Leads within Manx Care
Clinical Leads within Manx Care should ensure that healthcare staff have the appropriate competencies to the level of care they are providing for acutely ill/deteriorating patients, in line with the Royal College of Physicians, NEWS2 score for assessing patients at risk of deterioration.
Matched on
terms: news, score
CQC action
44match
Chorley and South Ribble Hospital
The service should continue to monitor the correct recording of NEWS2 observations.
Matched on
terms: news
NCEPOD recommendation
41match
Community-Acquired Pneumonia
Matched on
classifier match
CQC action
41match
Bridlington Hospital
The service should audit MEOWS so that they are assured the system is being using effectively.
Matched on
classifier match
CQC action
34match
Wexham Park Hospital
The service should ensure correct and effective use of MEOWS and NEWTT charts to accurately identify deteriorating patients.
Matched on
classifier match
Inquiry recommendation
32match
F243 - Recording of routine observations
The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot be done, there needs to be a system whereby ward leaders and named nurses are responsible for ensuring...
Matched on
classifier match
NCEPOD recommendation
32match
Prison Healthcare
Matched on
classifier match
PHSO casework decision
31match
P-004158 - Gloucestershire Hospitals NHS Foundation Trust
Miss G complained about a lack of nurse escalation, surgical review, and delayed treatment for her father, Mr G, after he deteriorated, leading to his death.
Matched on
classifier match
PHSO casework decision
23match
P-003718 - Homerton Healthcare NHS Foundation Trust
Ms X complained nursing staff failed to escalate her father's care for medical review, possibly preventing his death and denying her a chance to say goodbye. She also complained about poor complaint handling.
Matched on
classifier match
PHSO casework decision
23match
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.
Matched on
classifier match