We made safety recommendations to The Royal College of Physicians and NHS England/NHS Improvement as a result of our investigation into recognising and responding to critically unwell patients.

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.

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

Royal College of Physicians

We recommended that the Royal College of Physicians (RCP) National Early Warning Score (NEWS) advisory group continues to evaluate the implementation and use of NEWS2 - the latest version of this tool.

In response, the RCP has formed the NEWS2 advisory group to evaluate the implementation and use of NEWS2 collaborating with system experts and leaders from NHS England/NHS Improvement, Academic Health Science Networks, the Royal College of General Practitioners and prominent healthcare professionals from the field of deterioration and sepsis.

NHS England and NHS Improvement

We recommended that NHS England/NHS Improvement should expand the remit of the cross-system Sepsis Board to include physical patient deterioration, involving additional stakeholders as required.

In response, NHS England/NHS Improvement have broadened the remit. 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.

Safety recommendations and responses in full

Read the safety recommendations in this report and the responses from the RCP and NHSE/NHSI in full on the recognising and responding to critically unwell patients investigation page.