Missed and inaccurate patient observations
151 items
2 sources
Failure to conduct or accurately record essential patient observations, leading to missed medical reviews and delayed intervention.
Cross-Source Insight
Missed and inaccurate patient observations has been flagged across 2 independent accountability sources:
2 inquiry recs
149 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (2)
F243 — Recording of routine observations
Recommendation: The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
R15 — CDI patient observations records
Recommendation: Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Gov response: Section 4.2 of the Scottish Government's response outlines professional standards for record-keeping. The revised NMC code, which all nurses and midwives must follow, specifically requires them to complete all records accurately and without any falsification, …
Accepted
PFD Reports (149) — showing 100 most recent
Bruce Caulfield
Concerns: Concerns include delays in medical reviews after family concerns, insufficient intentional rounding impacting vulnerable patient hydration, and inconsistent communication practices for fall prevention across the Trust.
Pending
Dennis Price
Concerns: Failures in inpatient post-fall reviews, unclear neurological observation plans, and inefficient electronic system escalations compromised patient safety.
Overdue
Judith Hughes
Concerns: The hospital's fall risk assessment tool is confusing due to unclear factor definitions, risking incorrect scores, insufficient observation levels, and increased patient falls.
Response: The Trust's 'Enhanced Care Risk Assessment Form' was revised in 2022 to clarify the distinction between 'previous falls in the last 12 months' and 'inpatient fall during this admission'. Nursing …
Responded
Gloria Simon (1)
Concerns: A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Response: Marine Lake Medical Practice acknowledges the care provided was below expected standards and plans a formal Significant Event Analysis to review the case. They will also review and take action …
Responded
Gloria Simon (2)
Concerns: Miscommunication about the care home's status led a GP to not visit. Care home staff lacked training on obtaining urgent clinical input when a GP declined and failed to consistently take, record, and act on basic patient observations.
Response: Riversdale Care Home has updated its 'Request for Care Form' to correctly identify as a 'Care Home'. They have also revised their policy to send letters to out-of-district GPs for …
Responded
Alan Horrocks
Concerns: Patient observations were not completed per escalation guidance, delaying deterioration recognition. Increased ward capacity without corresponding nursing staff and existing staffing gaps compromised patient care.
Response: Bradford Teaching Hospitals has convened a multi-disciplinary Case Review Panel which has already considered the identified issues regarding observations and the adequacy of investigation reports. They also plan to roll …
Responded
Stephen Neville
Concerns: Nursing staff failed to properly conduct and record therapeutic observations due to misunderstanding and training deficits. The quality assurance and auditing processes for these critical observations were also found to be severely inadequate.
Response: The Trust has updated its Observation Policy and a new training module, rolled out to all clinical staff by December 2025, with a new observation proforma also being implemented. It …
Responded
[REDACTED]
Concerns: There were widespread failures in the quality, accuracy, and auditing of patient observations, including staff distraction during crucial monitoring. Concerns also persist regarding the door-locking system's reliability and staff guidance for its failure.
Response: The East London NHS Foundation Trust states that no further action is required for most concerns due to significant work already undertaken since the patient's death, which has resulted in …
Responded
Sarah Heaver
Concerns: Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.
Responded
Emily Hewerdine
Concerns: Patients faced inadequate hydration assessments and fluid charting, nursing failures to identify deterioration, and a lack of clinical assessment in the Emergency Department before mental health referrals or discharge.
Overdue
Finlay Roberts
Concerns: There is a concerning widespread lack of serial paediatric nursing observations, with medical staff failing to identify their absence, leading to an unsafe patient discharge.
Responded
Pamela Brand
Concerns: Hospital records lacked key details regarding patient observations and clinical decision-making rationale, posing a risk to the quality of future patient care.
Response: The Trust has implemented new digital care planning, a safety alert learning bulletin, and specific documentation projects for fluid balance, thromboprophylaxis, and discharge summaries. Training on record-keeping was delivered in …
Responded
Upali Meththananda
Concerns: Poor clinical documentation, including absent observations, key event records, and inter-clinician discussions, meant treating clinicians lacked a full patient picture, risking future care errors.
Responded
Esme Atkinson
Concerns: Insufficient training for community healthcare professionals in identifying infant heart defects, especially with maternal diabetes, and inadequate auditing of cardiac anomaly scans contribute to delayed diagnosis.
Responded
Keith Inseon
Concerns: Care home record-keeping was inaccurate and incomplete, as observation scores after a fall were not consistently recorded, hindering proper assessment for escalation to medical services. The system remains unaddressed.
Responded
Billie Wicks
Concerns: The emergency department was understaffed, leading to missed vital observations and delayed antibiotic administration. Inadequate staff training on adult onset asthma and ineffective safety netting advice contributed to the death.
Responded
Allan Taylor
Concerns: Level 2 EICO observation guidelines requiring a nurse to be within sight or sound were not met, as the patient's side room was too far. This lack of escalation and compliance likely contributed to an unwitnessed fall.
Responded
Yemisi Cielto-Opaleye
Concerns: Inadequate patient consent regarding Olanzapine depot injection risks, insufficient observation protocols post-injection, and failures in medication change approval processes including SOAD checks, risked fatal Post Injection Syndrome.
Responded
John Riley
Concerns: Observations were consistently late or not performed at required intervals, indicating a failure to adhere to vital patient monitoring protocols in the care home.
Responded
Kashim Ali
Concerns: Patient safety was undermined by unescalated NEWS2 scores, staff distraction during one-to-one observations, and inaccurate record-keeping, creating significant risks for future patients.
Responded
Jean Thomas
Concerns: Critical fluid balance monitoring for a patient with severe cardiovascular and renal issues, complicated by sepsis, was entirely neglected by both nursing and medical staff.
Responded
Robert Taylor
Concerns: Critical enhanced nursing observations were not implemented despite identified need, and the subsequent investigation inadequately addressed this failure or actions to prevent recurrence.
Responded
Mia Gauci-Lamport
Concerns: Inadequate night monitoring, including reliance on an insensitive video monitor, and poor medical record keeping compromised Mia's care. Lack of regular PEWS assessments and inconsistent specialist oversight were significant clinical governance concerns.
Responded
Kay Simmonds
Concerns: Incorrect NEWS score calculation and subsequent failure to follow observation protocols led to missed recognition of a deteriorating patient, delaying senior medical review and putting lives at risk.
Responded
Wendy Hammon
Concerns: Critical indicators of deteriorating health (rising CRP, fluid charts, NEWS2 scores) were consistently missed or incomplete by clinical staff, suggesting a systemic lack of knowledge and inadequate monitoring.
Responded
Anna Elliot
Concerns: The unit experienced widespread poor record-keeping, inadequate observation chart entries, and a rising trend of missed and falsified observations, indicating a failure to adhere to critical safety protocols despite training and previous PFD reports.
Responded
Mahamoud Ali
Concerns: Repeated instances of falsified observation records on mental health wards, despite previous interventions, indicate insufficient action to ensure patient safety and prevent future deaths.
Responded
Margaret Pilgrim
Concerns: A patient was discharged with an unrecognised and untreated fractured clavicle, which was also omitted from the discharge summary, leading to delayed care.
Responded
Bernard Compton
Concerns: The emergency department lacked effective patient oversight and systems to action urgent blood results or ECG findings, alongside failures in ambulance service assessment and timely response for a critical cardiac condition.
Responded
David Scott
Concerns: Hospital practice of not reporting vascular calcification on X-rays, even when it could indicate serious Peripheral Vascular Disease in conjunction with other symptoms, is inconsistent with expected standards and poses a risk.
Responded
James Pearson
Concerns: Lack of documented observations, insufficient doctor staffing for multiple critical patients, and delayed access to blood products hindered timely intervention, contributing to a patient's rapid deterioration and cardiac arrest.
Overdue
Orlando Davis
Concerns: Midwives lacked awareness of the risk of hyponatremia in birthing women, leading to inappropriate fluid management, inadequate monitoring, and subsequent severe brain injury to the baby.
Responded
Nuliyati Businje
Concerns: DVT risk assessment tools inadequately assess mobile or psychiatric patients, and clinicians lack awareness that observations can normalise despite a persistent clot, leading to missed diagnoses and increased VTE risk.
Responded
Paul Perrott
Concerns: Inadequate observation charting, unclear staff responsibility for checks, and a lack of historical risk analysis meant staff were unaware of the patient's critical suicide risk history.
Overdue
Valerie Simmons
Concerns: Observations were not consistently undertaken when a patient's condition changed, and staff require further training on the risks of hypovolaemia in anti-coagulated patients.
Responded
Adam Stuyvesant
Concerns: The Emergency Department's DVT risk assessment failed to consider lower limb immobility from plastic boots, risking patients not receiving crucial anti-clotting medication and developing fatal pulmonary embolisms.
Overdue
Sultana Choudhury
Concerns: Failures included not diagnosing an obvious renal haemorrhage, administering VTE prophylaxis with active bleeding, and inadequate patient monitoring, leading to preventable deterioration.
Responded
Harry Stobie
Concerns: Following PEG tube insertion, a patient's deteriorating condition and abdominal pain were not adequately monitored or escalated to a senior doctor, potentially missing a critical bleed.
Responded
Alan Nippard
Concerns: Grossly inadequate basic nursing care led to preventable pressure sores, marked by incorrect risk assessments, delayed preventative equipment, poor adherence to care bundles, and insufficient patient repositioning.
Responded
Marion Nickson
Concerns: Observable bay nursing failed due to staff being pulled away for other tasks, highlighting a lack of prioritisation for patient observation and resourcing issues that hinder effective falls prevention.
Responded
Jane Wadsworth
Concerns: Missed critical medication doses, lack of senior medical input during holiday periods, and ineffective communication for ICU referrals and specialist discussions contributed to a patient's deteriorating condition.
Responded
Elizabeth Agbejimi
Concerns: A significant abnormal respiratory acidosis reading was not further investigated, potentially indicating a training or communication failure that contributed to the patient's death from a respiratory condition.
Responded
Raquel Harper
Concerns: Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.
Overdue
Alice Fox
Concerns: The patient faced significant risk from prolonged discharge lounge stay and late night transfer without proper admission assessments. Delayed recognition and confirmation of infection, compounded by false reassurance from NEWS scores, led to missed opportunities for earlier treatment.
Overdue
Maureen Dick
Concerns: Medical staff exhibited a lack of professional curiosity and inadequate assessment of severe pain and a pressure ulcer, delaying diagnosis. There is also no mandatory training for clinical staff on pressure ulcers.
Overdue
Doris Smith
Concerns: Inadequate falls risk assessments and observations, alongside poor communication, confusing policies, and substandard electronic record-keeping, compromised patient safety.
Responded
Shahan Aman
Concerns: Miscommunications among nursing and medical staff, coupled with a discharging doctor's failure to check recent observations, led to a patient's concerns being overlooked before an inappropriate discharge.
Responded
Delina Etienne
Concerns: Critical failures included a chaotic cardiac arrest response, non-escalation of elevated blood pressure, lack of VTE risk assessment, and unreviewed chest pain. Misinformation regarding a DNACPR was also not promptly admitted.
Responded
Eliot Harris
Concerns: Critical patient observations were not carried out or recorded correctly, staff lacked training and competency, and there were issues with task allocation, record keeping, and ensuring staff safely enter rooms for patient welfare checks.
Responded
Richard Scott-Powell
Concerns: Critical NEWS2 scores and abnormal vital signs were not escalated, vital signs were inconsistently recorded or vaguely noted as "okay," indicating a lack of clear policies and training for observation management.
Responded
Manhareen Kaur
Concerns: There is no system for monitoring high-risk babies on postnatal wards, leading to insufficient observations and delayed detection of collapse in infants requiring assisted delivery or resuscitation.
Overdue
Mandy Dickerson
Concerns: System glitches prevented mandatory sepsis template use, hindering timely diagnosis. There was confusion over inter-departmental patient referrals, and critical patient observations were not recorded or conveyed to specialists.
Responded
Sarah-Louise Doyle
Concerns: Predictable timing of patient observations allowed for potential self-harm planning, indicating a need for more frequent and unpredictable monitoring practices within mental health settings.
Responded
David Clark
Concerns: Care in ICU was not escalated appropriately despite adequate staffing, with inaccurate NEWS score calculation and generally poor clinical documentation compromising patient safety.
Overdue
Darran Busby
Concerns: A critical flaw in the electronic patient record system allows radiology results requiring urgent follow-up to be inadvertently filed without clinician review, risking missed diagnoses and treatment delays.
Responded
Harbans Singh
Concerns: The discharge process experienced a system failure, and significant hypothyroidism identified by blood tests was not flagged or acted upon, posing a risk to patient safety.
Responded
Janet Willcock
Concerns: Crucial opportunities were missed to auscultate the patient's chest in A&E and before surgery, leading to a missed new heart murmur that should have triggered an urgent cardiology referral.
Responded
Azra Hussain
Concerns: Critical family concerns about a suicide attempt were not recorded or escalated, and known ligature points in en-suite bathrooms remained unmitigated, indicating failures in risk assessment and safety.
Responded
Rodney Gates
Concerns: Critical patient observations were missed due to low numbers of nursing staff, heavy reliance on agency nurses with limited experience, and a lack of essential equipment on the ward.
Responded
Joan Rutter
Concerns: Poor record-keeping, especially during night shifts, obscured important resident events. The delivery of overnight care meant staff were often unaware of residents needing assistance, posing risks.
Overdue
Paula Speirs
Concerns: There was a lack of formal observations or monitoring for an intoxicated patient, and nurses were untrained in recognising or preventing positional asphyxia in a hospital setting.
Responded
Frank Medley
Concerns: The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Responded
Ruby Baggaley
Concerns: Critical deterioration in a post-surgical patient was not escalated to senior clinicians despite persistently high NEWS scores and abnormal vital signs. Unclear escalation procedures and inadequate staff training risk similar future incidents.
Responded
Evadney Dawkins
Concerns: Critical renal monitoring was delayed for four days, leading to a Grade 3 acute kidney injury. The Trust's governance systems also failed to promptly investigate this as a serious incident.
Responded
David Kerr
Concerns: Medical care on ward D2 was poor, with inadequate fluid management leading to severe dehydration and a critical lack of regular clinical observations for a seriously unwell patient.
Responded
Allan Cunliffe
Concerns: Poor physical care on Summers Ward was identified, characterized by inadequate communication between doctors and nurses, inaccurate clinical observation recording, and staff confusion regarding oxygen administration and mandatory training.
Responded
Edna Davenport
Concerns: The care home failed to provide a disabled patient with a call alarm or adequate observations, lacked documentation for care plans, and did not properly assess or manage the risk posed by an aggressive resident, leading to an assault and neglect of head injury monitoring.
Overdue
Matthews Rogers
Concerns: Patient observations were not monitored hourly as required for a high NEWS score, likely due to nurse understaffing and high patient numbers, indicating an omission in care.
Overdue
Frances Gibb
Concerns: There were serious and recurring failings in the application and use of the National Early Warning Score (NEWS) system, indicating a systemic risk to patient safety.
Responded
Dorothy Macey
Concerns: Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.
Overdue
Pamela Moran
Concerns: Missed opportunities for a CT scan and lack of a system for overnight consultants to authorise scans contributed to delayed diagnosis and potentially preventable death.
Overdue
Lauren Finch
Concerns: Nursing staff conducted predictable patient observations against policy, which was misunderstood by managers, and made delayed clinical record entries, failing to provide timely, vital information for subsequent shifts.
Responded
Pamela Evans
Concerns: Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Responded
Tillie Spencer-Adams
Concerns: Serious fractures and head injuries sustained in a road traffic collision were critically overlooked when the deceased attended the hospital.
Responded
Gladys Borgogno
Concerns: Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.
Responded
James Francis
Concerns: Critical patient information, including a recent fall and observation requirements, was not effectively communicated during shift handovers. There were also significant delays in seeking medical attention for deteriorating health and insufficient information provided to paramedics.
Responded
Jonathan McCarthy
Concerns: The Trust failed to correctly monitor blood sugar and ketones, administered incorrect insulin, and provided inadequate nursing care with a failure to escalate concerns.
Responded
Royston Kemp
Concerns: A care home nurse failed to adequately assess a resident's deteriorating leg condition, take vital signs, or escalate concerns, leading to a missed diagnosis of a fractured femur.
Overdue
Kenneth Whittington
Concerns: Hospital failures included missing post-operative catheter instructions, an unchecked epidural disconnection despite patient pain, and a system preventing direct consultant follow-up after surgery.
Responded
Gwyneth Edwards
Concerns: Inadequate weekend transfer protocols, staff failing to action NEWS scores, and a flawed Mobile Medic system marking incomplete requests as done, coupled with staffing pressures, jeopardized patient monitoring and record-keeping.
Overdue
Michael Flynn
Concerns: Systemic failure to monitor EWS, adhere to review protocols for deteriorating patients, and ensure consultant oversight, compounded by an unavailable ICU outreach team and poor fluid chart completion.
Responded
Janice Davies
Concerns: Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
Responded
William Atherton
Concerns: Failure of medical review, unrecognised worsening condition, missing nursing observations, and incorrect, inconsistently applied Early Warning Scores prevented proper escalation of patient care.
Overdue
Kalma Ram-Henman
Concerns: Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, and neglected opportunities to assess a deteriorating patient after transfer.
Responded
Doris Ridgwell
Concerns: A critical communication failure meant an abnormally high INR result for a Warfarin patient was not effectively relayed or acted upon before discharge, leading to fatal complications.
Overdue
Kirsty Tolley
Concerns: Inconsistent blood test monitoring for anaemia and inadequate Early Warning Score (EWS) assessment and escalation to doctors led to missed opportunities for intervention and a lack of clear medical cause of death.
Responded
Christine Withers
Concerns: Crucial repeat blood tests for potassium levels were not performed as recommended, and nursing staff failed to adequately communicate with family about the patient's deteriorating condition.
Responded
James Sheffield
Concerns: Delays occurred in diagnosis and surgical intervention for a fracture, and a patient's essential CPAP machine went missing during hospital ward transfer.
Responded
Barbara Johnson
Concerns: Junior doctors routinely ignored diagnostic printouts from ECG machines, which flagged abnormalities, raising concerns about the impact on clinical interpretation and judgment.
Responded
John Lea
Concerns: Incomplete risk assessments, poor nursing communication, significant documentation gaps, and a failure to escalate concerns about a non-attending doctor led to incorrect patient scores and policy non-adherence.
Overdue
John Scallan
Concerns: Patient observations were inconsistent and inadequate, failing to detect deterioration in a sedated patient. Staff lacked understanding of observation policy and were reluctant to conduct proper in-room checks, relying instead on distant sightings.
Overdue
Rodney Hampshire
Concerns: The surgical ward currently lacks monitored beds, which a review suggests could potentially save lives by improving patient surveillance.
Responded
Patricia Forshaw
Concerns: The hospital discharge card provided ambiguous contact information, leading to incorrect telephone advice being given and unrecorded critical observations by staff. Despite 'gross miscommunication,' a Serious Incident Review was not undertaken.
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Responded
Dorothy Webb
Concerns: A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.
Responded
Dennis Redmore
Concerns: Clear failures in neurological monitoring, with substantial observation gaps and delayed action on elevated vital signs, were identified. There was also a lack of appropriate management to ensure nurses adhered to observation guidelines.
Responded
Edith Robinson
Concerns: Lack of weekend consultant review, inaccurate early warning score calculation, and consistently poor record-keeping by staff compromise patient safety, risking delayed diagnosis and treatment.
Responded
Alaanuloluwa Joseph
Concerns: Inaccurate monitoring and recording of fluid intake and output, a critical aspect of sepsis management, was not undertaken.
Overdue
Joleen Linton
Concerns: Concerns about inadequate and unreliable hourly patient observations due to environmental factors, inaccurate record-keeping, undetected errors, staff reluctance to enter rooms, and a poorly defined observation policy.
Overdue
Clive Davies
Concerns: Failures in conducting routine neurological and NEWS observations, including missed checks and an incorrectly calculated score, resulted in the deceased not receiving a necessary medical review.
Overdue