NEWS score over-reliance
Delayed infection diagnosis due to over-reliance on National Early Warning Score (NEWS) without comprehensive assessment.
26 items
4 sources
1 inquiry
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
81match
Frances Gibb
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.
Matched on
terms: news, score
PFD report
77match
Della Calvey
Unsafe practice of routinely downgrading NEWS scores for all COPD patients without knowing individual baseline saturations leads to inadequate clinical assessments.
Matched on
terms: news, score
PFD report
73match
Dave Onawelo
Inadequate monitoring of a high-risk patient with sickle cell anaemia, coupled with delayed interventions and emergency department issues like congestion and over-reliance on algorithms, contributed to a fatal outcome.
Matched on
terms: over, reliance
PFD report
73match
Dhananji Dona
The hospital failed to implement the specialist National Early Warning Score matrix for prenatal women across all departments, risking inadequate monitoring without plans for timely introduction.
Matched on
terms: score
PFD report
69match
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: news, score
PFD report
69match
Kay Simmonds
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.
Matched on
terms: news, score
PPO recommendation
63match
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: news, score
PFD report
61match
June Parkes
Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.
Matched on
terms: news
PFD report
61match
Alexander Braund
There are continuous failures in applying the NEWS2 system for acutely unwell patients in a secure setting due to insufficient training, guidance, and robust compliance auditing, risking deaths from unrecognized deterioration.
Matched on
terms: news
PFD report
57match
Denise Prior
Inadequate hospital record-keeping for oxygen levels, prescription, and the application of the NEWS system poses a risk of future deaths.
Matched on
terms: news
PFD report
57match
Graham Fox
Junior nursing staff misunderstood that clinical responses under the NEWS system were mandatory, believing discretion could be applied, despite additional training.
Matched on
terms: news
PFD report
57match
Simon Healey
NEWS policies at private hospitals should be reviewed, particularly regarding escalation of care for critically unwell patients, considering their limited critical care capacity. Nursing staff on general wards may lack experience in managing post-operative complications like leaks or sepsis.
Matched on
terms: news
PFD report
57match
Khairul Rahman
The prison healthcare system lacks robust, accurate documentation of clinical interactions and response times. There is also an unclear and inconsistent application of the NEWS2 scoring system for monitoring patient deterioration.
Matched on
terms: news
PFD report
57match
Tammy Watkins
Persistent failures in physical healthcare within mental health settings, including staff not recognizing deteriorating patients, non-adherence to NEWS2 policy, and confusion in emergency call procedures, led to preventable deaths.
Matched on
terms: news
PFD report
53match
Carla London
Concerns were raised about the need to consider NICE guidance on late-onset sepsis in premature babies and to research infection monitoring systems to improve early detection and treatment.
Matched on
classifier match
PFD report
53match
Alice Gibson-Watt
A recurring failure to identify and appropriately escalate acutely physically unwell patients in mental health settings, compounded by insufficient vital sign monitoring and inconsistent use of early warning systems.
Matched on
classifier match
PPO recommendation
47match
Clinical Leads within Manx Care
Clinical Leads within Manx Care should ensure that healthcare staff have the appropriate competencies to the level of care they are providing for acutely ill/deteriorating patients, in line with the Royal College of Physicians, NEWS2 score for assessing patients at risk of deterioration.
Matched on
terms: news, score
PHSO casework decision
39match
P-004158 - Gloucestershire Hospitals NHS Foundation Trust
Miss G complains of a lack of escalation from nurses to medics, a lack of surgical review and a delay in treatment from the time her father, Mr G, showed signs of deterioration over a 24 hour period in November 2021, with consistent pain, low blood pressure and a distended abdomen.
Matched on
terms: over
Inquiry recommendation
32match
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
classifier match
PHSO casework decision
23match
P-003718 - Homerton Healthcare NHS Foundation Trust
Ms X complains that nursing staff failed to escalate her father’s care for medical review in line with guidance in March 2020.
Matched on
classifier match
PHSO casework decision
23match
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.
Matched on
classifier match