“Any National Early Warning Score (‘NEWS2’) should always be escalated”

The coroner’s concerns

1) Any National Early Warning Score (‘NEWS2’) should always be escalated. However, during Mr Ali’s time on Millharbour Ward he achieved a NEWS2 score on more than one occasion, which was not escalated to the nurse in charge for review. While this was not a causative factor in Mr Ali’s death, I consider that it creates significant risk for other patients in future, if not addressed. 2) During part of his on Millharbour Ward, Mr Ali was on one-to-one observations, requiring him to always be within the sight of a dedicated member of staff. Following Mr Ali’s death, it transpired that during this period of observations, designated members of staff were noted to preoccupied with the use of their personal mobile telephones at times, and on one occasion, the designated member of staff was sat on a chair with their back to Mr Ali’s door. While this was not a causative factor in Mr Ali’s death, I consider that such practices undermine patient safety and would place future patients at considerable risk. 3) The Trust noted, during its own serious incident investigation, that the quality of record keeping in relation to Mr Ali’s observations was not always accurate. Given the key role that accurate record-keeping plays in patient care within any healthcare setting, I formed the view that this also creates significant risk. I heard evidence that the Trust is taking the above matters seriously and that they are going to be addressed at Board level. However, it was acknowledged that there was still work to do to address the risks identified.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0582

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0