Delayed Recognition of Deterioration
Failure to timely recognize, report, and escalate deteriorating patient conditions, leading to delayed intervention.
1,566 items
13 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
73match
Stephen Palmer
Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.
Matched on
terms: delayed, deterioration
PFD report
69match
Jude Augustus Gordon
Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Matched on
terms: delayed
PFD report
69match
Mr Pether
Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Matched on
terms: delayed
PFD report
65match
Linda Rignall
A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Matched on
terms: deterioration
PFD report
65match
Freda Owens
There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.
Matched on
terms: delayed
PFD report
65match
Philip Smith
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.
Matched on
terms: deterioration
PFD report
61match
Selina Broadhurst
Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Matched on
terms: delayed
PFD report
61match
Mark Hudson
Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Matched on
terms: delayed
PFD report
61match
David Mountain
Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.
Matched on
terms: delayed
PFD report
61match
Lana-Liza Chervonenko
High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Matched on
terms: delayed
PHSO casework decision
60match
P-002652 - Stockport NHS Foundation Trust
Mrs E complains the Trust delayed recognising signs of deterioration and symptoms of COVID-19 and delayed her mother’s COVID-19 test. She also complains that staff would not allow the whole family to be at her mother’s bedside in her final hours.
Matched on
terms: delayed, deterioration
IMB annual report
59match
Dartmoor (2024)
The report for HMP Dartmoor covers a year dominated by uncertainty and eventual temporary closure due to elevated Radon gas levels, leading to extensive prisoner decanting. While initial safety metrics remained low and in-cell phones improved wellbeing, the period was marked by delayed decision-making from HMPPS, significant estate deterioration, and challenges in maintaining a consistent regime and purposeful...
Matched on
terms: delayed, deterioration
PFD report
57match
Keward Guy Domonic Harding
An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Matched on
terms: delayed
PFD report
57match
Caroline Lee
Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
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PFD report
57match
Herta Woods
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.
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PFD report
57match
Ashley Ponsonby
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.
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PFD report
57match
Albert Flynn
Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
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classifier match
PFD report
57match
Evelyn Smith
Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
Matched on
terms: recognition
PFD report
57match
Peter Dorney
Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
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classifier match
PHSO casework decision
57match
P-004243 - The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
Mrs B complains The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust delayed reviewing her father for two days following a fall, did not catheterise him when he needed this, and did not appropriately manage his condition when he started to deteriorate.
Matched on
terms: delayed
PFD report
53match
Edna Elsie Mary Eden
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.
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PFD report
53match
Margaret Easterfield
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
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PFD report
53match
Noel Williams
The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
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PFD report
53match
John Dodd
Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
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PFD report
53match
Gary Bradshaw
The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
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PFD report
53match
Peter White
Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
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PFD report
53match
Ella Block
Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.
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PFD report
53match
Kirsty Pritchard
There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.
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PFD report
53match
Sonielia Holmes
The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting advice and review of the patient.
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PFD report
53match
Susanna Geraty
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.
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Committee recommendation
53match
#10 - Long elective care waiting times pose serious risks to patient health and mortality
We received written evidence that long waiting times can put patients at risk. Evidence from Dr Rob Findlay noted that if it is not known what is wrong with undiagnosed patients then some of them will unexpectedly turn out to have a clinically urgent condition such as cancer.17 The National Institute 12 C&AG’s Report, paras 1.2 and 1.7-1.8...
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PHSO casework decision
52match
P-003304 - The Hillingdon Hospitals NHS Foundation Trust
Mr V complains the Trust delayed admitting his father on 29 August 2023, and did not perform a CT head scan despite him reporting stroke symptoms.
Matched on
terms: delayed
PFD report
49match
Lucy Kilvert
A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
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PFD report
49match
James Edward Mansfield
Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
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PFD report
49match
Barbara White
Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
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PFD report
49match
Jean James
Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
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PFD report
49match
Matthew Simmonds
An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
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PFD report
49match
Frances Bell
The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
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PFD report
49match
Stephen Atherton
The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.
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PFD report
49match
Yaser Saleh
The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
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PFD report
49match
Mary Hallworth
A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.
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PFD report
49match
Harold Penny
The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.
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PFD report
49match
Stephen Mayoll
The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
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PFD report
49match
Mikey Hornby
The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked essential diagnostic facilities.
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CQC action
49match
BMI Southend Private Hospital
The service must ensure that there are safe processes in place for monitoring of the deteriorating patient. Including the safe transfer of a patient to another healthcare facility.
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PPO recommendation
48match
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: deterioration
PPO recommendation
48match
The Governor and Head of Healthcare at HMP Woodhill
The Governor and Head of Healthcare at Woodhill must ensure that urgent healthcare appointments are not delayed.
Matched on
terms: delayed
PHSO casework decision
48match
P-001634 - George Eliot Hospital NHS Trust
Mrs O complains about the Trust's care of her husband, Mr O. She says it delayed admitting him for care and doing investigations to find the right treatment. She says it was too late to treat his stomach cancer and it spread.
Matched on
terms: delayed
PHSO casework decision
48match
P-002294 - University Hospitals Coventry and Warwickshire NHS Trust
Mrs A complains about the Trust's care of her mother in 2018. She says it delayed treatment, did not look into her breathing difficulties fully meaning it missed an enlarged thyroid that was compromising her windpipe, and it removed a tracheostomy tube when she was still struggling to breathe. She also says the Trust did not provide a...
Matched on
terms: delayed
PHSO casework decision
48match
P-003007 - Lewisham and Greenwich NHS Trust
Mrs R complains the Trust delayed diagnosing her hip dislocation for three days because it did not take an X-ray following hip replacement surgery. She also complains the Trust did not consider her needs or obtain informed consent for surgery.
Matched on
terms: delayed