The screen of a patient monitor in a hospital.

Recognising and responding to critically unwell patients

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

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).