Our latest report, published 23 May 2019, recommends tackling the recognition and response to deteriorating patients with the same national approach driving improvement in identifying and treating sepsis. 

Major source of severe harm and preventable death

Problems in recognising and responding to patients who are deteriorating 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. 

In our report, we set out one recommendation to NHS England /NHS Improvement to extend the remit of their successful cross-system sepsis programme board to include deterioration from conditions other than sepsis. This comes after we launched a national investigation based on the case of a 58-year old woman who deteriorated and died, less than 24 hours after presenting at the Emergency Department with a potentially treatable condition. 


The investigation examined the context of the Emergency Department and various models of patient assessment used, as well as the factors that influence decision making. This includes communication tools, how information is delivered, environmental pressures (for example noise and interruptions), time constraints and a focus on meeting performance standards.

Statement from the Director of Investigations

Dr Stephen Drage, Director of Investigations at HSIB, said: “Our investigation very much highlighted that it is not easy to improve situation awareness and decision making. The emphasis has to be on designing an effective system to make sure the right information is getting to the right place at the right time, creating a holistic picture of the patient.

“This is why we have made the recommendation to extend the remit of the national programme board. They have already had great success with their work, and there has been an increase in the identification and timely treatment of sepsis. We felt it would be beneficial to bring together experts and leaders in the field, so that there is a more unified approach taken in tackling the recognition and response to critically unwell patients.

“Recognising and treating deterioration in patients is something clinicians have to deal with every day in busy hospitals and ultimately our safety recommendations are designed to reduce the devastating impact this has on staff, patients and their families.” 

Statement from national lead in sepsis and deterioration 

Dr Matt Inada-Kim, Consultant Acute Physician and a national lead in sepsis and deterioration, who worked with the team throughout the investigation, commented: “This independent HSIB report shines a light on the benefits that healthcare will gain through learning what other industries have done when tackling similar problems. 

“Though healthcare is unique, in its complexities and situation, there are some key transferrable human factors lessons such as standardisation to a common language (NEWS2), communication (spoken, non-verbal, written and electronic), situational awareness and mental modelling; all ideas that can make healthcare safer. 

“We have such a wonderful opportunity to build upon the findings of this report at scale and develop a sustainable vision of how we can address and improve outcomes within the condition that is the largest cause of avoidable harm in healthcare.” 

National Early Warning Scores

The report also sets out a second recommendation focused on the use of NEWS (National Early Warning Scores). The investigation found that there was research to suggest that the way it was escalated places a high demand on staff resource. The work done on NEWS and the feedback incorporated into NEWS2 was recognised by the investigation. HSIB have recommended to the Royal College of Physicians to continually evaluate the implementation and use of NEWS2. The team also observed that NEWS2 shouldn’t be used as a stand-alone tool and should be combined with other patient information. 

Read the report

Download and read the ‘Recognising and responding to critically unwell patients’ report.