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
Source spread
Where this theme appears
Missed and inaccurate patient observations has been flagged across 5 independent accountability sources:
2 inquiry recs
149 PFD reports
10 PPO recs
1 IMB rec
56 PHSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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.
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 50 strongest matches
John Lansdowne
Concerns: 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.
Overdue
Stuart Aaron Collins
Concerns: 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.
Response (South Tees Hospitals NHS Foundation Trust): The Trust states that they have undertaken a full investigation and discussed the matter at a senior level. They maintain that the patient was assessed on arrival at A&E and …
Overdue
Edna Elsie Mary Eden
Concerns: 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.
Response (Heatherwood Wexham Park Hospital NHS Trust): The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage …
Responded
Herta Woods
Concerns: 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.
Overdue
Peter Norman Nott
Concerns: 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.
Response (Elizabeth Finn Homes): Rush Court care home has reviewed its policies and procedures when dealing with a resident who has experienced an unwitnessed fall. Neurological observations will commence using the Glasgow Coma Scale …
Responded
Natasha Raghoo
Concerns: 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.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
Sebastian Davies
Concerns: Hourly night observations failed to check for patient immobility or movement, potentially delaying detection of unconsciousness, and lacked continuity among observing staff.
Overdue
John Dodd
Concerns: Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Response (The Dudley Group NHS Foundation Trust): The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will …
Responded
William Winter
Concerns: Understaffing and unfamiliarity with escalation procedures on a Clinical Decisions Unit led to missed patient observations and delayed surgical review.
Overdue
Gregg O’Reilly
Concerns: 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.
Response (Barts Health NHS Trust): Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board …
Responded
Ashley Ponsonby
Concerns: 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.
Response (Greater Manchester Police): • Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions. • It is often appropriate and necessary for legal proceedings …
Responded
Vivian Hunt
Concerns: Neurological observations were critically missed for several hours following a patient's two falls, despite visible injuries.
Response: The Health Board developed a Corrective Action Plan for Improvement to ensure effective action regarding compliance with neurological investigations post head injury, with actions taken by the Mental Health Directorate.
Responded
Irshad Ali
Concerns: 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.
Response (Barts Health NHS Trust): The Trust has taken multiple actions including monthly nursing audits of patient note filing, reminders to nurses about discharge policies, and a review of processes. Training for nurses in neurological …
Responded
Linda Rignall
Concerns: A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Overdue
Zakariyya Clark
Concerns: 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.
Overdue
Maureen Ellett
Concerns: Initial A&E documentation was flawed, with critical patient information like blood pressure and Glasgow Coma Scale omitted from the front sheet.
Response (Brighton Sussex University Hospitals NHS Trust): Agreement has been reached with SECAMB that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. The Trust is …
Responded
Peter Dorney
Concerns: Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Response (North Bristol NHS Trust): North Bristol NHS Trust clarified that all new nurses receive mandatory Early Warning Score (EWS) training on induction and that 93% of all nurses have received EWS training. The directorate …
Responded
Awa Jeng
Concerns: 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.
Response (Barts Health NHS Trust): The trust is implementing a revised early warning score system (NEWS and CREWS), has been awarded funding to implement a vital signs monitoring process (Vitalslink), has a full complement of …
Responded
Philip Smith
Concerns: 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.
Overdue
Robert Jones
Concerns: 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.
Response (The Health Centre): The GP practice shared the hospital's action plan with their GPs and will have ongoing discussions with the hospital. The hospital updated its falls policy, implemented falls assessments on admission, …
Response (Northern Devon Healthcare NHS Trust): The Trust's falls policy has been revised to include information relating to the frequency and duration of neurological observations, and published on the Trust's policy website. Targeted training on performing …
Overdue
Susanna Geraty
Concerns: 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.
Response (Surrey Sussex NHS Trust): SASH has introduced mandatory training for newly qualified nurses on fluid balance and has issued a reminder to staff regarding the importance of accurately completing fluid balance charts. A Serious …
Responded
John Matthews
Concerns: 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.
Response (Stockport NHS Trust): The Trust has formally discussed neurological observation needs in sisters' meetings and safety huddles, shared within the ED Quality Newsletter to all ED staff. To avoid a reoccurrence the Trust …
Responded
Paul Moroney
Concerns: 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.
Response (Tameside Hospital NHS Trust): The Trust asserts that oxygen saturations were monitored and recorded, contrary to the coroner's concern, and apologises for the lack of clarity during the inquest. They provide copies of the …
Responded
Jane Robinson
Concerns: 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.
Response (University Hospitals of Leicester NHS Trust): The Trust is implementing a competency assessment for HCAs by the end of October 2015 and moving towards electronic recording of observations with automatic EWS calculation and alerts. Clinical handover …
Responded
Philip Robinson
Concerns: 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.
Response (Doncaster Bassetlaw Hospitals NHS Trust): The Trust completed an "observations project" including documentation of EWS on discharge and implemented a safety brief at shift changes. They are also planning to implement the i-Hospital whiteboard system …
Responded
Elsie Hayward
Concerns: 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.
Response (Cardiff Vale University Health Board): Cardiff Vale University Health Board has already undertaken actions including ward-level board rounds, safety briefings, MDT meetings, disciplinary investigation of a nurse, and staff retraining, following an internal investigation and …
Responded
Robert Payne
Concerns: 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.
Overdue
Derrick Stanmore
Concerns: 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.
Response (Leicestershire Partnership NHS Trust): An adapted version of the Track and Trigger system will be introduced, with staff trained in its use across the three Prison Healthcare Teams by October 2015. Staff will be …
Responded
Evelyn Kennedy
Concerns: 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.
Response (Brighton and Sussex University Hospitals NHS Trust): The Trust has been undertaking work, including improved consultant cover, a working group to address practices and documentation, developing specialist areas, improving signage, improving information handover, and increased monitoring of …
Responded
Parv Patel
Concerns: The report identifies that PEWS scores may not reflect current research into child illness, particularly in cases of sepsis, and may distract doctors from the fact that a child is seriously ill despite a low score.
Response: The response acknowledges concerns about PEWS scores and describes ongoing national work by NHS England and the Royal College of Paediatrics and Child Health to develop a framework for recognising …
Responded
Piotr Kucharz
Concerns: 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.
Response: The Trust is planning an external review of its new clinical risk assessment tool and policy in April 2016. A revised observation policy and procedure will be implemented by 31 …
Responded
Shalini Ganesh-Ram
Concerns: The report identifies that a raised pulse, abdominal pain and lack of urine output did not prompt a CT scan and a surgical consult was not sought until four days post operation, suggesting suboptimal care due to issues within the system.
Overdue
Robin Brett
Concerns: 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.
Overdue
Leslie Murray
Concerns: 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.
Overdue
David Hughes
Concerns: 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.
Response (David Hughes): The Trust has completed a cycle of recruitment into new general nurse posts at the Bradgate Unit and has commenced a second cycle; the service will review this strategy and …
Responded
Marie Rollason
Concerns: The report identifies a potential lack of recognition of the deceased's repeated loss of consciousness prior to hospital readmission.
Response (Royal Wolverhampton NHS Trust): The Royal Wolverhampton NHS Trust confirms that clinical staff in the Emergency Department receive regular training in the identification and treatment of pulmonary embolism. A training session on venous thromboembolism …
Responded
Elsie Raper
Concerns: 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.
Response (elsie Raper): The surgery will implement several actions, including investigation of falls in elderly patients and prompt referral for x-rays, as well as regular reviews of factors contributing to falls and discussion …
Response (Four Seasons Health Care): Four Seasons Health Care has initiated 24-hour falls observation charts, completed a list of all residents with a confirmed diagnosis of osteoporosis, reviewed and rewritten residents' care plans to incorporate …
Responded
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and …
Responded
Christopher Brand
Concerns: 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.
Response (West London Mental Health NHS Trust): West London Mental Health Trust has implemented monthly checks of observation windows on each ward, and staff have undertaken mandatory training in observation and engagement skills. They are commissioning Immediate …
Responded
Constance Pridmore
Concerns: Rib fractures and a subsequent haemothorax were not identified on admission, leading to undetected blood accumulation and death during a chest drain insertion procedure.
Response (University Hospitals of Morecambe Bay NHS Trust): The Trust has undertaken several actions to address radiology reporting delays, including offering overtime to consultants, supporting undergraduate radiographer training, maximizing advanced practitioner skills, employing locums, introducing advice and guidance …
Response (Department of Health): The Department of Health is increasing clinical radiology training posts by 32 in 2016 and is reviewing specialty intakes from 2017 onwards, taking into account the Urgent and Emergency Care …
Responded
Margaret Gleeson
Concerns: 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.
Response (Wrighton Wigan and Leigh NHS Trust): The Trust reviewed staffing levels, provided refresher training on the MEWS tool, and conducted sepsis training, including drop-in sessions and mandatory attendance at a Sepsis Study Day for nursing staff, …
Responded
Margaret Tuck
Concerns: 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.
Response (Barths Health NHS Trust): Barts Health NHS Trust has re-instructed staff on falls risk assessments and care plans, clarified nursing responsibilities, reinforced post-falls procedures, and implemented measures to improve communication between medical teams. They …
Responded
Vinod Kumar
Concerns: 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.
Overdue
Matthew Llewellyn-Jones
Concerns: 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.
Response (Devon Partnership NHS Trust): Devon Partnership NHS Trust has locked the doors at the Cedars since the inquest and notified entrances that the door is locked; patients are informed on admission, and LED signs …
Responded
Nihad Ousta
Concerns: 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.
Overdue
Alfred Grimshaw
Concerns: 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.
Response (East Lancasshire Hospitals NHS Trust): The Trust has strengthened communication processes for complex frail patient discharges, with emphasis on the Multidisciplinary Team and improved information transfer between primary and secondary care. The case has been …
Responded
Anthony McManus
Concerns: The system of patient observations was flawed, with nurses performing non-random, fixed-time checks, some observations not conducted, and charts completed retrospectively.
Overdue
Robert Entenman
Concerns: 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.
Response (London Bridge Hospital): London Bridge Hospital implemented several changes including introduction of bedside monitoring and nursing observations policy, the use of SBAR and DOPES handover techniques, and Human Factors Training. They have also …
Response (NMC): The NMC acknowledges the concerns and states that they are currently investigating the matter in accordance with their statutory functions and will provide a further update in due course.
Response (CQC): The CQC details findings from a 2013 inspection where the hospital met standards for staff training and incident reporting. The hospital introduced a critical care daily safety briefing sheet in …
Overdue
Beryl Farmer
Concerns: 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.
Response (Sandwell and West Birmingham Hospitals NHS Trust): The Trust is amending its inpatient falls policy to ensure post incident monitoring is undertaken and will more clearly link standards in ED and on the wards. Face to face …
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
PPO Death in Custody Recommendations (10)
The Head of Healthcare
The Head of Healthcare should ensure that when healthcare staff complete vital observations, they use the NEWS2 scoring system as a standard procedure.
The Head of Healthcare
The Head of Healthcare should ensure that clinical observations are taken and recorded when a prisoner is unwell.
The Head of Healthcare
The Head of Healthcare should ensure that: when a prisoner needs clinical observations, these are completed; and staff refer prisoners appropriately to the mental health team.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a MUST assessment when a person is weighed and ensure any concerns are escalated with immediate effect.
The clinical regional manager of Oxleas NHS Trust
The clinical regional manager of Oxleas NHS Trust should: provide assurance to NHS England – Southwest in relation to the repeated recommendations made at HMP The Verne regarding use of the NEWS2 tool; provide a timeframe and assurance on when …
The Head of Healthcare
The Head of Healthcare should ensure that the healthcare team adhere to NICE guideline: Suspected cancer: recognition and referral, by escalating changes in a patient’s weight to the GP who can then decide on the most appropriate plan of care.
The Head of Healthcare
The Head of Healthcare should ensure that red flag symptoms are communicated effectively between team members to ensure there is no delay in appropriate examination and onward referral.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff routinely review patients with high blood pressure results.
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.
The Head of Healthcare
The Head of Healthcare should ensure that all staff are aware of the normal range for clinical observations, the relevance of finding an abnormal physical observation and action to take when this is noted.
PHSO Casework Decisions (56)
P-004078 — Hampshire Hospitals NHS Foundation Trust
Miss G complains staff did not monitor her father adequately and respond to his ventilation equipment disconnecting. She also complains staff did not let her visit her father and a poor investigation into possessions which went missing during her father’s admission.
NHS in England
Upheld
Sep 2025
P-004140 — Oxford University Hospitals NHS Foundation Trust
Miss A complains about the aftercare her daughter received following a kidney and pancreas transplant at the Trust. She says the Trust should have been caring for her daughter in the intensive care unit and did not monitor her heart rate or carry out appropriate observations.
NHS in England
Oct 2025
P-004170 — A practice in the Boston area
Mrs H complains about aspects of care and treatment her husband, Mr J received from the Surgery between 23 and 26 May 2023. She says the Surgery misdiagnosed Mr J and failed to carry out the appropriate observations/tests.
NHS in England
Partly Upheld
Oct 2025
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.
NHS in England
Nov 2025
P-001061 — Royal Free London NHS Foundation Trust
Mr E complains that during 4 visits to the Emergency Department (ED), staff failed to identify and treat the cause of his left arm and chest pain. He says they failed to take his medical history and his previous visits to the ED that week into account and failed to …
NHS in England
Partly Upheld
Apr 2021
P-001068 — Portsmouth Hospitals NHS Trust
Mrs L complains about aspects of treatment provided by Portsmouth Hospital NHS Trust (the Trust) when she attended A&E, following a fall in which she hurt her back. Specifically, Mrs L complains that the A&E registrar concerned did not share with her information, that he believed he found evidence of …
NHS in England
Partly Upheld
May 2021
P-001195 — A healthcare provider in the Knowsley area
Mrs R complained about care and treatment provided by a Practice in the Knowsley area. She complained that she was incorrectly diagnosed with menopausal symptoms, however she was admitted to hospital later that day with an infection.
NHS in England
Partly Upheld
Jul 2021
P-001588 — A medical practice in the London Borough of …
Mrs C complains the Practice incorrectly diagnosed her on 7 May 2020. She also complains it did not call her back when she said her left arm was numb and she thought the symptoms could be related to her heart.
NHS in England
Sep 2022
P-001568 — A medical practice in the Southampton area
Mr O complains the Practice misdiagnosed his brother's severe pain as sciatica
NHS in England
Oct 2022
P-001612 — University Hospitals Sussex NHS Foundation Trust
Mrs M complains the Trust did not monitor or treat her husband’s constipation appropriately and did not keep him well hydrated. This led to him suffering a perforated bowel.
NHS in England
Partly Upheld
Nov 2022
P-003884 — King's College Hospital NHS Foundation Trust
Miss A complains about how the Trust cared for her brother. She complains it did not monitor him properly and he got sepsis, it did not give him the right fluids and the complaints process took too long.
NHS in England
Jul 2023
P-003824 — Harrogate and District NHS Foundation Trust
Mr A complains the Trust failed to correctly diagnose a fracture in his back and to give appropriate treatment for his injury. He also complains he got different medical opinions from different doctors at the Trust.
NHS in England
Sep 2023
P-002548 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr Y complains about the care and treatment the Trust gave to his daughter. He thinks her death may have been avoided if she had better monitoring, was given more oxygen and the Trust did not attempt to cannulate her.
NHS in England
Not Upheld
Apr 2024
P-002651 — Northumbria Healthcare NHS Foundation Trust
Mr R complains about the care provided to his late wife, Mrs R in August 2021. He complains that the Trust did not take Mrs R’s medical history into consideration, and did not recognise, monitor, or escalate Mrs R’s deterioration.
NHS in England
Not Upheld
May 2024
P-002700 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr P complains the Trust misdiagnosed his partner with alcohol-related liver disease in July 2021. He complains that after this the Trust failed to consider her liver problems, to test for autoimmune conditions or to take a liver biopsy to find a definitive cause.
NHS in England
Jun 2024
P-002728 — A practice in the Gloucestershire area
Miss E complains the Practice failed to check her lymph nodes and behind her ear during several appointments and did not refer her to ENT specialists. She also says the Practice did not provide her with the results from blood and urine tests.
NHS in England
Jun 2024
P-002742 — A practice in the Lincolnshire area
Mrs O complains the Practice missed multiple opportunities to investigate and diagnose her husband's cancer symptoms between March and May 2023.
NHS in England
Upheld
Jul 2024
P-002763 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss T complains staff at the Trust did not keep her mother adequately hydrated, check her pressure areas and keep her oxygen saturation within the target range.
NHS in England
Partly Upheld
Jul 2024
P-002867 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr X complains about the nursing care given to his wife one night in March 2022. He says the nurse failed to check and assess his wife from 10pm to 6.30am the next morning.
NHS in England
Aug 2024
P-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust did not appropriately monitor her brother, Mr Z, when he was undergoing Trial Without Catheter (TWOC), and did not respond adequately when he developed a life-threatening complication.
NHS in England
Mar 2025
P-003804 — Warrington and Halton Hospitals NHS Foundation Trust
Mr A raised concerns about the Trust’s care of his father, specifically that it failed to properly monitor his post-operative condition following hip replacement surgery and failed to escalate concerns regarding his deteriorating condition. He also raised concerns about the Trust’s communication with his mother in the day leading up …
NHS in England
Aug 2025
P-004029 — King's College Hospital NHS Foundation Trust
Ms X complains that the Trust failed to escalate and monitor her father's care in line with guidance.
NHS in England
Partly Upheld
Sep 2025
P-004034 — Isle of Wight NHS Trust
Mrs F complains about the care and treatment Isle of Wight NHS Trust provided to her father, Mr P, during an inpatient admission from 11 December 2022 to 25 December 2022. Mrs F specifically complains about the Trust’s decision to move her father from the Intensive Care Unit, how he …
NHS in England
Sep 2025
P-003963 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs G complains that Ashford and St Peter's Hospitals NHS Foundation Trust did not provide appropriate care, treatment, and monitoring to her mother during her admission following a cardiac arrest in the community.
NHS in England
Partly Upheld
Sep 2025
P-004142 — A practice in the Mid Devon area
Mrs H complains a nurse practitioner failed to properly assess her daughter, Miss G, when she visited the Surgery on 16 February 2024 with breathlessness. Mrs H is also unhappy with its handling of her subsequent complaint.
NHS in England
Oct 2025
P-004300 — Mid and South Essex NHS Foundation Trust
Miss J complains that Mid and South Essex NHS Foundation Trust did not appropriately monitor her mother, Mrs K, or her condition when she was stepped down from its High Dependency Unit (HDU) to a standard ward in July 2023.
NHS in England
Nov 2025
P-001299 — A medical practice in the Hertfordshire area
Mr M complains that his GP did not properly assess his symptoms after he collapsed at home on 24 September 2020. He later went to the hospital where it was discovered he had suffered a heart attack.
NHS in England
Feb 2022
P-001327 — Wrightington, Wigan and Leigh NHS Foundation Trust
Mrs A complained that the Trust did not take sufficient action to appropriately investigate her husband’s symptoms in March and May 2018. She told us on both occasions her husband suffered from bleeds in his throat and mouth that were not investigated.
NHS in England
Mar 2022
P-001322 — Northampton General Hospital NHS Trust
Mrs B complained on behalf of her son, Mr N, about the treatment he received from Northampton General Hospital NHS Trust after a road traffic accident. She said the Trust failed to arrange an MRI scan, misdiagnosed a spinal injury, and discharged him without any follow up care.
NHS in England
Mar 2022
P-003819 — Northern Care Alliance NHS Group
Mrs F complains the Trust did not manage her husband's nutrition and hydration, delayed giving him medication, missed signs that he had sepsis and did not treat him quickly enough.
NHS in England
Sep 2023
P-002530 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs R complains about the care and treatment her son had when he was admitted in January 2022. She says despite doing regular routine tests, the Trust failed to identify a serious problem.
NHS in England
Upheld
Apr 2024
P-002698 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mr O complains the Trust failed to diagnose his wife’s gallbladder cancer, leading to her unnecessary death.
NHS in England
Partly Upheld
Jun 2024
P-002718 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs A complains the Trust did not diagnose her husband with stomach cancer after he was referred and did not promptly refer him for a laparoscopy after diagnosis.
NHS in England
Not Upheld
Jun 2024
P-002712 — Dartford and Gravesham NHS Trust
Mr O complains the Trust failed to diagnose the cause his wife's condition despite her being admitted five times with the same symptoms and that it did not give her the right care and treatment during these admissions.
NHS in England
Partly Upheld
Jun 2024
P-002776 — A practice in the Newcastle upon Tyne area
Mrs N complains the Practice did not do enough to diagnose and treat her son's bronchiolitis despite many visits to see a GP.
NHS in England
Jun 2024
P-002783 — Calderdale and Huddersfield NHS Foundation Trust
Mrs P complains about the care and treatment given to her mother between November and December 2022. She says the Trust failed to give her steroids on 28 November 2022, delayed arranging an urgent CT scan and delayed a diagnosis of giant cell arteritis.
NHS in England
Jul 2024
P-002749 — North West Anglia NHS Foundation Trust
Miss U complains the Trust failed to regularly monitor and control her father's iron levels and it failed to give him albumin.
NHS in England
Partly Upheld
Jul 2024
P-003003 — East Sussex Healthcare NHS Trust
Miss A complains that clinicians failed to act on her mother’s high risk of falls in December 2022. She says her mother had two serious accidents and sustained significant injuries. Miss A also believes documentation was falsified.
NHS in England
Sep 2024
P-003135 — Dorset Healthcare University NHS Foundation Trust
Mrs F complains that an out-of-hours GP’s failure to not take observations or do a physical examination meant her grandmother’s infection was not found and she was wrongly advised to go home.
NHS in England
Nov 2024
P-003276 — Stockport NHS Foundation Trust
Ms U complains about the Trust’s care of her mother in April 2021. She says it did not do enough to reduce the risk of a stroke, it failed to diagnose the stroke and did not monitor her mother’s bowels for eight days, delaying a diagnosis of bowel obstruction.
NHS in England
Partly Upheld
Jan 2025
P-003291 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs T complains the Trust inserted a stent into her husband and failed to remove it. She also complains nurses failed to complete appropriate observations and failed to provide appropriate care.
NHS in England
Partly Upheld
Jan 2025
P-003420 — Mid Yorkshire Teaching NHS Trust
Miss Y complains about the Trust’s care and treatment of her father in January 2023. She complains about a lack of observation, assessment, and investigation of her father’s condition. She also says the Trust did not communicate how unwell her father was.
NHS in England
Upheld
Mar 2025
P-003424 — A practice in the Walsall area
Miss R complains the Practice did not take appropriate action to investigate her late sister’s symptoms when she had bladder cancer and prescribed antibiotics that did not help. Miss R also complains the Trust failed to diagnose her late sister’s bladder cancer, did not investigate her symptoms properly, provided no …
NHS in England
Partly Upheld
Mar 2025
P-003454 — A practice in the Gloucestershire area
Ms G raised concerns about the care provided by the Practice, as she felt opportunities were missed to diagnose an ongoing infection.
NHS in England
Mar 2025
P-003559 — Cambridge University Hospitals NHS Foundation Trust
Miss G complains that clinicians from a hospital at the Trust did not properly monitor her eye condition and did not respond to warning signs which suggested an impending perforation during January 2022.
NHS in England
May 2025
P-004475 — A practice in the South Gloucestershire area
Miss X complains about the care and treatment her three-year-old daughter received from the Practice in November 2024. She says the Practice did not diagnose her daughter’s pneumonia and fluid on her lungs, reassured her that her daughter was well despite ongoing symptoms, and failed to investigate or escalate her …
NHS in England
Not Upheld
Dec 2025
P-004519 — A practice in the North Yorkshire area
Ms C complains about the care and treatment she received from her GP Practice in the North Yorkshire Area during an appointment in October 2023 when presenting with concerns regarding discomfort in her breast.
NHS in England
Not Upheld
Dec 2025
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.
NHS in England
Partly Upheld
Dec 2025
P-001321 — A medical practice in the Norfolk area
Miss E complained about the care and treatment she received from the Practice between 21 December 2015 and 15 September 2017, stating that it did not take her injuries seriously.
NHS in England
Mar 2022
P-002554 — Hull University Teaching Hospitals NHS Trust
Mr A complains the Trust missed opportunities between August and September 2023 to diagnose his mother with gangrene in her foot.
NHS in England
Apr 2024