Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has shown that up to a quarter of preventable deaths are related to failures in clinical monitoring.

Investigation summary

The reference event in this investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery.

The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.

The national investigation explored the human factors which may influence recognition and response to a patient who is critically unwell.

It focused on:

  • situation awareness and decision making
  • patient assessment models for the emergency department
  • the number of publications and guidelines available to clinicians and the use of the National Early Warning Score (NEWS).

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Safety recommendations

We made safety recommendations to The Royal College of Physicians (RCP) and NHS England and NHS Improvement as a result of this investigation. Both organisations responded to the safety recommendations within 90 days of publication of the investigation report.

The Royal College of Physicians

Safety recommendation

It is recommended that the Royal College of Physicians NEWS advisory group continues to evaluate the implementation and use of NEWS2, including but not limited to:

  • The use of NEWS2 in practice, in particular the consistency of recording, the consistency of response, and the communication of patient measurements between healthcare professionals.
  • The effectiveness of NEWS2 in identifying a patient’s level of acute illness in different care settings and patient groups.
  • The presentation of NEWS2 information and how this supports clinicians to identify trends, particularly in electronic records.
  • The guidance and training on the use of NEWS2 as part of clinical assessment and patient monitoring.


The Royal College of Physicians has formed the NEWS2 advisory group to evaluate the implementation and use of NEWS2 collaborating with system experts and leaders from NHS Improvement, NHS England, AHSNs [Academic Health Science Networks], the RCGP [Royal College of General Practitioners] and prominent healthcare professionals from the field of deterioration and sepsis.

Through this group, and in part informed by this report, we recognise that there are key areas of focus including assessing the use of NEWS2 in practice and its effectiveness in identifying the level of acute illness in different patient groups and settings, how the presentation of NEWS2 supports clinicians to identify trends, and training on the use of NEWS2.

Over the next 12 months we aim to:

  • Provide, as appropriate, support to clinicians using NEWS2, for example, guidance around the new confusion score to be published within the RCP NEWS2 FAQs.
  • Support the development of additional e-learning modules covering the common challenges faced by clinicians using NEWS2.
  • Seek to work with companies that provide electronic recording platforms to move towards consistency of products for recording NEWS2.
  • Ensure that the RCP NEWS2 website is an effective mechanism for sharing case studies of good practice and lessons learned from the implementation and use of NEWS2.
  • Support the continuation of embedding NEWS2, and the learning from its use and implementation throughout the NHS.

This response was received on 7 August 2019.

NHS England and NHS Improvement 

Safety recommendation

It is recommended that NHS England/NHS Improvement should expand the remit of the Cross-System Sepsis Programme Board to include physical patient deterioration, involving additional stakeholders as required.


NHS England and NHS Improvement have broadened the remit of the previous cross-system Sepsis Board. With the agreement of the National Quality Board the new group will be called the Acute Deterioration Board. Its purpose is to ensure alignment between programmes of work being carried out by various national and regional healthcare organisations to improve the prevention, identification and rapid action in response to acute physical deterioration.

This response was received on 8 August 2019.

Find out more by reading our report launch news story.