NEWS score over-reliance
Delayed infection diagnosis due to over-reliance on National Early Warning Score (NEWS) without comprehensive assessment.
Source spread
Where this theme appears
This theme appears across 8 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
15 PFD reports
4 HSSIB recs
4 CQC actions
7 PPO recs
3 PHSO decisions
1 MNSI report
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.
Prevention of Future Deaths reports(15)
Denise Prior
Concerns: 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.
Response (Western Sussex Hospitals NHS Trust): • The Trust undertook a thorough investigation and review. • The Trust enclosed an action log detailing the actions taken. (AI summary)
Responded
Carla London
Concerns: 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.
Response (Department of Health): • The Department stated that plans include an audit of GP surgery practice by March 2015 and a new tool for GPs to diagnose sepsis in children under 5. • … (AI summary)
Responded
June Parkes
Concerns: 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.
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
Alice Gibson-Watt
Concerns: 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.
Response (NHS England): • NHS England noted that Care Quality Commission (CQC) inspections in mental health settings examine the employment of staff with the necessary skills for physical healthcare. • NHS England highlighted … (AI summary)
Responded
Graham Fox
Concerns: 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.
Response (University Hospitals Bristol NHS Trust): • The Trust implemented an e-observations system that automatically calculates the National Early Warning Score (NEWS), prompts staff for repeat observations, and facilitates escalation to clinicians. • The Trust promoted … (AI summary)
Responded
Simon Healey
Concerns: 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.
Response (IHPN): • IHPN began a learning programme with the Care Quality Commission (CQC) to promote best practice in safety and will discuss escalation policies with the CQC. • IHPN will undertake … (AI summary)
Overdue
Frances Gibb
Concerns: The coroner identified serious deficiencies in the use of the National Early Warning Score (NEWS) system.
Response (Brighton and Sussex NHS Trust): • The Trust implemented an electronic patient observation system (Patientrack) across adult and paediatric inpatient areas, which automatically calculates National Early Warning Scores (NEWS) and prompts staff. • Staff on … (AI summary)
Responded
Khairul Rahman
Response (Practice Plus Group): • Practice Plus Group stated it would continue to work with NHSE/I and HMPPS to resolve mobile connectivity challenges for SystmOne. • Practice Plus Group updated a record keeping training … (AI summary)
Overdue
Alexander Braund
Concerns: 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.
Response (TPP LTD): • TPP LTD clarified that the SystmOne electronic patient record system maintains a complete and robust audit trail. • TPP LTD explained that the system visually indicates when a record … (AI summary)
Response (HM Prison and Probation Service): • An annual training plan has been introduced for staff, covering medical emergency roles and cell entry protocols. • A process is in place to review incidents, identify non-compliance, and … (AI summary)
Response (Nottingham Healthcare NHS Foundation Trust): • The Trust requested all Offender Health employees to complete online NEWS2 training, reporting 86% completion by February 2023, and relocated the NEWS2 emergency template in SystmOne for easier access. … (AI summary)
Responded
Tammy Watkins
Concerns: 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.
Response (Nottinghamshire Healthcare NHS Foundation Trust): • The Trust recruited an Associate Director of Physical Healthcare and commenced a review of physical health models of care across inpatient services. • NEWS2 training has been delivered to … (AI summary)
Responded
Kay Simmonds
Concerns: 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.
Response (Aneurin Bevan University Health Board): • The Health Board undertakes daily One Patient One Day audits and NEWS audits to monitor compliance with nursing documentation and observation protocols. • The Urgent Care Division met with … (AI summary)
Responded
Dave Onawelo
Concerns: 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.
Response (Department of Health and Social Care): • The Department noted that the Barts Health NHS Foundation Trust would be taking action to improve awareness and care for sickle cell anaemia patients and to increase the number … (AI summary)
Overdue
Dhananji Dona
Concerns: 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.
Response (NHS England): • NHS England developed national digital specifications to support the implementation of the national Maternity Early Warning Score (MEWS) across both maternity and non-maternity clinical environments. • NHS England published … (AI summary)
Response (University Hospitals of North Midlands NHS Trust): • The Trust established an operational group to develop a Trust-wide approach for the Maternity Early Warning Score (MEWS). • A paper-based MEWS process will be rolled out across the … (AI summary)
Responded
Della Calvey
Concerns: 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.
Response (Aneurin Bevan University Health Board): • The Health Board launched NEWS2 in September 2025, and all flow centre staff completed the required training. • Call handling staff are trained to calculate NEWS scores without adjustment, … (AI summary)
Response (Welsh Ambulance Service NHS Trust): • The Trust stated it would not support clinicians to routinely downgrade a National Early Warning Score (NEWS). • Organisational learning has taken place. • Changes are being made to … (AI summary)
Responded
HSSIB safety recommendations(4)
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
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 …
Safety Action
Sepsis: a patient with abdominal pain
New confusion in patients is not consistently accounted for in NEWS2 scores.
Area of Improvement
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, …
Safety Recommendation
NCEPOD recommendations(2)
CQC inspection actions(4)
Bridlington Hospital
The service should audit MEOWS so that they are assured the system is being using effectively.
Should Do
Dorset County Hospital
TheserviceshouldensureMEOWSandNEWSchartsarecompletedcorrectlyandusedtoeffectivelyidentifyand escalatedeterioratingpatients.
Should Do
Wexham Park Hospital
The service should ensure correct and effective use of MEOWS and NEWTT charts to accurately identify deteriorating patients.
Should Do
Chorley and South Ribble Hospital
The service should continue to monitor the correct recording of NEWS2 observations.
Should Do
PPO death in custody recommendations(7)
The Head of Healthcare
The Head of Healthcare should review whether the monthly compliance monitoring of staff’s use of the NEWS2 scoring system is sufficiently robust.
The Head of Healthcare
The Head of Healthcare should ensure that when staff take clinical observations, they: • record the readings in the prisoner’s medical record; and • calculate and record the NEWS2 score and know when to escalate care as a result.
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.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff consistently use the National Early Warning Score 2 (NEWS2) to assess patients and are trained to use the appropriate scale for those with respiratory failure.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: are fully competent in using the National Early Warning Score (NEWS2) effectively; complete full and accurate clinical observations; follow protocols for clinical escalation in line with NEWS2 and sepsis pathways; and …
The Head of Healthcare
The Head of Healthcare must ensure that all healthcare staff are trained and competent in the use of the NEWS2 assessment.
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 …
PHSO casework decisions(3)
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.
NHS in England
Partly Upheld
Oct 2025
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.
NHS in England
Upheld
Jul 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