Missed and inaccurate patient observations
Failure to conduct or accurately record essential patient observations, leading to missed medical reviews and delayed intervention.
218 items
5 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
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: missed, observation, patient
PFD report
89match
William Winter
Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Matched on
terms: missed, observation, patient
PFD report
89match
Vinod Kumar
Initial triage over-relied on the patient's fall, leading to delayed recognition of potential infection symptoms, missed observations, and inadequate prolonged assessment before priority categorization.
Matched on
terms: missed, observation, patient
PFD report
85match
Clive Davies
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.
Matched on
terms: missed, observation
PFD report
81match
Vivian Hunt
Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Matched on
terms: missed, observation, patient
Inquiry recommendation
78match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Matched on
terms: observation, patient
PFD report
77match
Stuart Aaron Collins
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Matched on
terms: observation, patient
PFD report
77match
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.
Matched on
terms: observation, patient
PFD report
77match
Robert Jones
Communication failures meant staff were unaware of a patient's total falls, an outdated post-falls checklist was used, and neurological observations were not correctly recorded per NICE guidelines.
Matched on
terms: observation, patient
PFD report
77match
Derrick Stanmore
A registered nurse failed to recognise abnormal patient observations requiring escalation, and lacked access to essential healthcare records to contextualise findings. A system like EWS is needed for recognition and escalation.
Matched on
terms: observation, patient
PFD report
77match
Margaret Gleeson
Hospital weekend staffing levels were inadequate, leading to poor patient care. The MEWS tool was inaccurately scored and poorly understood, indicating a need for refresher training.
Matched on
terms: inaccurate, patient
PFD report
73match
John Lansdowne
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
Matched on
terms: observation, patient
PFD report
73match
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.
Matched on
terms: missed, patient
PFD report
73match
Gregg O’Reilly
The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Matched on
terms: missed, observation
PFD report
73match
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.
Matched on
terms: observation, patient
PFD report
73match
John Matthews
Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Matched on
terms: observation, patient
PFD report
73match
Elsie Hayward
Overstretched medical staff due to excessive patient ratios led to care deficiencies, including neglected neuro observations and poor note-taking. This resulted in significant confusion and communication breakdowns between nursing and medical teams.
Matched on
terms: observation, patient
PFD report
73match
David Hughes
Critical patient observations were inconsistently performed and recorded, fluid balance charts were meaningless, patient bedrooms lacked call bells, and nursing staff showed insufficient understanding of physical illness signs.
Matched on
terms: observation, patient
PFD report
73match
Christopher Brand
Hospital staff failed to follow observation policy due to obscured views and delayed checking on a patient's welfare. Crucially, CPR was not initiated immediately after finding the patient unresponsive, causing dangerous delays.
Matched on
terms: observation, patient
PFD report
73match
Matthew Llewellyn-Jones
Ward security remains compromised by breached "locked doors" and predictable patient observations, deviating from best practice. The note-recording system lacks mandatory fields for crucial carer/family information on admission.
Matched on
terms: observation, patient
PFD report
73match
Anthony McManus
The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
Matched on
terms: observation, patient
PFD report
69match
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.
Matched on
terms: patient
PFD report
69match
Peter Norman Nott
Care home staff failed to perform adequate neurological observations following a patient's fall, relying on simple visual checks despite prolonged immobility and clear deterioration.
Matched on
terms: observation, patient
PFD report
69match
Natasha Raghoo
The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Matched on
terms: observation, patient
PFD report
69match
Sebastian Davies
Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Matched on
terms: observation, patient
PFD report
69match
Awa Jeng
A high-risk patient for renal failure was not closely monitored, and critical blood tests and checks directed by a consultant were not performed, indicating failures in monitoring, task handover, and medical review.
Matched on
terms: patient
PFD report
69match
Piotr Kucharz
Mental health staff displayed a critical lack of consistency and clarity on what constitutes an effective patient observation, with some failing to enter rooms or engage. This systemic ambiguity puts vulnerable patients at risk due to inadequate monitoring.
Matched on
terms: observation, patient
PFD report
69match
Robin Brett
A missed steroid dose went unnoticed due to a lack of system alerts on both paper and electronic drug charts for patients on long-term steroid therapy.
Matched on
terms: missed, patient
PFD report
69match
Alfred Grimshaw
A critical hip fracture was missed during initial assessment and an X-ray report. Pre-discharge physiotherapy and occupational therapy reviews were documented but not conducted, leading to discharge with unaddressed mobility issues.
Matched on
terms: missed
PFD report
69match
Beryl Farmer
A patient at high risk of falls lacked a falls assessment, was moved to an unmonitored bay, and received inadequate post-fall neurological observations and imaging after a significant head injury.
Matched on
terms: observation, patient
PFD report
65match
Irshad Ali
The report identifies missing records of required nursing observations, a failure to complete neurological observations before discharge as stipulated, and miscommunication regarding physiotherapy assessment before discharge.
Matched on
terms: observation
PFD report
65match
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.
Matched on
terms: patient
PFD report
65match
Jane Robinson
Basic observations were repeatedly not recorded, with no senior review or written rationale for observation frequency. A lack of reporting and support systems for non-compliant healthcare professionals was also found.
Matched on
terms: observation
PFD report
65match
Leslie Murray
Insufficient staffing on hospital wards prevents essential one-to-one patient care, leading to preventable falls and other critical care deficiencies that may contribute to patient deaths.
Matched on
terms: patient
PFD report
65match
Elsie Raper
A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Matched on
terms: patient
PFD report
65match
Margaret Tuck
Multiple failures included an absent falls prevention care plan, incomplete post-fall observations, confusion over nurse responsibility, and delayed investigation of confusion, contributing to undetected deterioration.
Matched on
terms: observation
PFD report
61match
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: patient
PFD report
61match
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.
Matched on
terms: patient
PFD report
61match
Robert Payne
Repeated falls for a high-risk patient, leading to further surgery, highlighted inadequate fall prevention. An early morning ward transfer lacked documentation, and the fatal fall was unwitnessed.
Matched on
terms: patient
PFD report
61match
Evelyn Kennedy
Acute Medical Unit failed significantly in patient care, with issues including incomplete handovers, poor personal hygiene, missing wristbands, unremoved IVs, incomplete care documentation, development of pressure damage, and unescalated NEWS scores indicating clinical deterioration.
Matched on
terms: patient
PFD report
61match
Robert Entenman
Nurses failed to notice an essential humidifier was off, partly due to the machine lacking an alarm. Significant delays occurred in identifying and replacing a blocked endotracheal tube, compromising patient care.
Matched on
terms: patient
Inquiry recommendation
61match
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
terms: observation
PPO recommendation
60match
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.
Matched on
terms: observation, patient
PFD report
57match
Zakariyya Clark
Significant deficiencies in A&E patient assessment and documentation, including vital signs and injury details, posed a risk to future patients if not addressed by system enhancements.
Matched on
terms: patient
PFD report
57match
Maureen Ellett
Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Matched on
terms: patient
PFD report
57match
Nihad Ousta
There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.
Matched on
terms: observation
PFD report
53match
Paul Moroney
Oxygen saturations were neither monitored nor recorded during the initial hospital visit and subsequent discharge, leading to a lack of crucial information upon re-admission.
Matched on
classifier match
PFD report
53match
Philip Robinson
Unclear ECG guidelines for breathlessness, unsatisfactory safe discharge audits, and inadequate communication of Early Warning Scores (EWS) are significant concerns. Delays in digital system implementation and the extreme risk of absent senior medical review compound these issues.
Matched on
classifier match
PHSO casework decision
52match
P-004312 - Frimley Health NHS Foundation Trust
Miss E complains the Trust failed to electronically record her father's, Mr E’s, vital observations and failed to escalate his care to on-call specialists when he passed blood during the night.
Matched on
terms: observation
PHSO casework decision
51match
P-004547 - University Hospitals Sussex NHS Foundation Trust
Mr B complains University Hospitals Sussex NHS Foundation Trust failed to appropriately examine his mother when she attended the Emergency Department, it did not complete necessary observations and missed diagnosing and treating her for sepsis.
Matched on
terms: missed, observation