When you or a loved one are admitted to hospital, you place your trust in the hands of the medical team. You expect that your condition will be closely watched and that, should your health take a sudden turn for the worse, the staff will notice immediately and take action. In a busy hospital environment, patient safety relies heavily on the ability of nursing and medical staff to spot warning signs early. When these signs are missed, or the response is too slow, the consequences can be life-altering. At Michael Boylan LLP, we understand the devastation families feel when a preventable deterioration leads to a severe injury or bereavement.
What “failure to monitor and escalate” means in hospital care
To understand where care can go wrong, it helps to distinguish between the three stages of patient observation.
- Monitoring: This is the routine checking of vital signs by nursing staff. It includes checking blood pressure, heart rate, respiratory rate (breathing), temperature, and oxygen levels. If these are not checked often enough, or if they are recorded inaccurately, the hospital is flying blind regarding the patient's condition.
- Escalation: This is the "alarm" phase. If the monitoring shows abnormal results (such as a drop in blood pressure or a spike in heart rate), the nurse must follow a protocol to alert a doctor. Escalation means explicitly telling a senior decision-maker, "This patient is deteriorating, come and review them now."
- Response: This is the action taken after the alarm is raised. It is of no use to escalate a problem if the doctor does not arrive promptly or, upon arrival, fails to take the necessary action (such as ordering a scan, starting antibiotics, or moving the patient to Intensive Care). A delay at any of these three stages can be fatal.
A claim for "failure to monitor and escalate" arises when the medical team fails to appreciate that a patient is getting sicker, or fails to call for senior help when the patient’s vital signs suggest they are in danger.
Recognising deterioration in Ireland: The INEWS System
Hospitals in Ireland do not rely on guesswork to decide when a patient is in trouble. They use a standardised system known as the Irish National Early Warning System (INEWS). This is a critical tool in patient safety, designed to remove ambiguity and ensure that every deteriorating patient gets a rapid response.
What INEWS is used for in Irish acute hospitals
INEWS is a "track and trigger" system. It tracks the patient's vital signs and triggers a response if the score gets too high.
Every time a nurse checks a patient's vitals, they assign a score to each measurement.
- A normal heart rate gets a score of 0.
- A slightly raised heart rate might get a score of 1 or 2 (Yellow or Orange).
- A severely abnormal rate gets a 3 (Red).
These numbers are added up to give a total Early Warning Score. The higher the score, the sicker the patient is likely to be. This removes personal opinion from the equation. It does not matter if a nurse "feels" the patient looks okay. If the score is high, the protocol dictates that action must be taken.
Escalation and response in practice
The INEWS protocol is strict about who must be called based on the score.
- Low Score: The nurse may just need to increase the frequency of checks (e.g., from every 4 hours to every hour).
- Medium Score: This usually requires the nurse to inform the nurse in charge and potentially call a junior doctor (Intern or SHO) to review the patient within a specific timeframe.
- High Score: This is a medical emergency. It typically mandates an immediate call to a Registrar or Consultant and may trigger an emergency response team.
In our investigations, we often look for the "Escalation Protocol" in the medical notes. We check if the score dictated a call to a Registrar, but only a junior doctor was informed. If the protocol required a review within 30 minutes, but the doctor arrived 2 hours later, that is a breach of the safety guidelines. Documenting these calls is vital.
When escalation protocols are modified
There are rare occasions where a doctor may decide that the standard triggers do not apply to a specific patient (for example, a patient with chronic lung disease who always has low oxygen levels).
However, this modification must be clearly written in the notes by a senior doctor. They cannot simply ignore the alarm. They must formally state, "This patient’s baseline is different, so we will tolerate a higher score before acting." If the score is ignored without a formal, documented modification, it is generally considered a failure to adhere to national standards.
Common scenarios where deterioration is missed
Hospital wards can be chaotic, loud, and understaffed. While this explains why mistakes happen, it does not excuse them. Patients rely on the hospital system to function regardless of how busy the ward is. In our experience, deterioration is most frequently missed in specific medical contexts where the signs can be subtle or easily mistaken for something else.
These contexts include post-operative complications, breathing difficulties, and sepsis.
Where these failures occur most often
While failures can happen anywhere, certain environments within the healthcare system are higher risk zones for missed deterioration.
- Emergency Department (ED): The transition from the ED (triage) to a ward is a danger zone. Patients in the ED are often on trolleys in corridors where monitoring is difficult. A patient might be assessed as "stable" on arrival, but deteriorate while waiting hours for a bed. If they are not re-assessed regularly during that wait, their condition can crash before they even reach a specialist ward.
- Surgical wards: The recovery period (the first 24-48 hours after surgery) is critical. Patients are often on strong painkillers which can mask symptoms. A failure to perform frequent post-operative observations is a common source of negligence claims.
- Medical wards: Failures often occur overnight or at weekends when staffing levels are lower. On a night shift, there may be fewer nurses per patient and junior doctors covering large numbers of wards. This can lead to "alarm fatigue" where staff become desensitised to call bells or warning beeps.
- Nursing homes: While not hospitals, nursing homes act as the primary residence for vulnerable people. A failure to recognise that a resident needs transfer to an acute hospital setting is a form of failure to escalate. If staff delay calling an ambulance for a resident with a hip fracture or pneumonia, the delay in hospital treatment can be catastrophic.
What a patient’s records typically show
When we investigate a claim regarding a failure to monitor, the medical records are the most important piece of evidence. The paper trail" (which is now often digital) tells the story of what the staff knew and when they knew it.
- Observation charts: These are the grids where nurses plot the vital signs (BP, Pulse, Temp). We look for gaps. For example, if the protocol says "monitor every 4 hours" but there is a gap of 8 hours with no entry, that is a breach of duty.
- Nursing vs Medical notes: There is often a discrepancy between what the nurses see and what the doctors write. Nursing notes might describe a patient who is "agitated, confused, and clammy." However, the doctor’s ward round note from the same morning might simply say "patient stable." This disconnect suggests the doctor did not read the nursing notes or failed to examine the patient thoroughly.
- Test results: We review blood tests and scans to see when the results became available. A delay in reviewing results is a failure to monitor.
- Escalation logs: We look for proof of the "call for help." Detailed logs are the only proof that the escalation protocol was followed.
When a poor outcome is not necessarily negligence
It is important to approach these cases with realism. Medicine is complex, and unfortunately, not every patient can be saved, even with the best care. A patient may deteriorate because their underlying illness is aggressive and unresponsive to treatment. A poor outcome does not automatically mean there was negligence.
For a legal case to exist, the deterioration must have been detectable and treatable. If a patient suffers a sudden, massive cardiac arrest with no prior warning signs, staff cannot be blamed for failing to predict it. However, if the patient had chest pain and dropping blood pressure for four hours prior, that is a different matter.
To pursue a case, we must establish the legal concept of duty of care, and prove two distinct elements:
- Breach of Duty: We must show that the monitoring or response fell below the standard expected of a reasonably competent medical team. This means proving that no competent team would have ignored those scores or delayed that long.
- Causation: This is often the most complex part. We must prove that if the staff had acted sooner, the outcome would have been different. We have to show that the delay made a material difference,for example, that earlier antibiotics would have prevented the organ failure, or earlier surgery would have saved the patient's life.
The legal assessment process for monitoring failures
If you suspect that a failure to monitor contributed to an injury or death, the legal process involves a forensic examination of the timeline.
Establishing the facts
We start by obtaining the full medical file. Our team, which includes legal professionals with medical knowledge, reviews the INEWS charts and nursing notes line by line. We construct a minute-by-minute chronology of the patient's admission. We match the patient's vital signs against the national guidelines to pinpoint exactly when the trigger was missed.
Public (HSE) vs Private hospitals
Whether the care took place in a public HSE hospital or a private clinic, the legal principles are largely the same. In public cases, the defendant is usually the HSE. In private hospitals, the defendant may be the hospital itself or the individual consultant, depending on their insurance arrangements. The standard of care required does not change; a patient in a private hospital is entitled to the same rigorous monitoring (using INEWS) as a patient in a public ward.
The role of independent experts
We cannot simply argue that the care was poor; we must prove it using expert evidence. We engage independent medical experts,senior consultants in relevant fields (such as Emergency Medicine, Nursing, or Surgery) who work in the UK or elsewhere. These experts review the files and provide an objective opinion on whether the care fell below the acceptable standard. Their report confirms what a competent doctor would have done in that situation.
Open Disclosure and the Patient Safety Act 2023
There have been significant changes to Irish law recently regarding honesty in healthcare. The Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023 creates a mandatory legal framework for Open Disclosure.
This Act mandates that if a serious "notifiable incident" occurs (such as a patient death directly related to a failure in care), the hospital must inform the family openly and honestly. They must explain what happened and apologise. This is a move away from the "deny and defend" culture of the past.
If you have been called to a meeting with hospital management where they admitted to a delay in diagnosis or treatment, this is part of the Open Disclosure process. It is vital that you take notes at this meeting. While an apology is not an automatic admission of legal liability for compensation purposes, the facts disclosed during this process are crucial evidence.
Time limits for medical negligence actions in Ireland
It is essential to be aware that there are strict time limits for bringing a medical negligence case in Ireland. This is known as the Statute of Limitations.
Generally, you have two years to issue legal proceedings. This clock usually starts ticking from the date the injury occurred.
However, in "failure to monitor" cases, the patient or family often does not realise negligence occurred until much later. In these cases, the "date of knowledge" rule applies. The two-year period will then start from the date you knew, or ought to have known, that the injury was caused by medical error.
Determining this date is legally technical, so acting immediately is always the safest course.
Exceptions for children and capacity
There are exceptions to the two-year rule:
- Minors: If the patient is a child, the time limit does not begin until they turn 18. They then have two years (until age 20) to bring a claim.
- Lacking Capacity: If the patient has suffered a brain injury or does not have the mental capacity to manage their own affairs, the time limits effectively do not apply for as long as that incapacity lasts.
Practical next steps if you suspect deterioration was missed
If you are concerned that medical staff failed to spot warning signs, it can be difficult to know where to start. You do not need to be a medical expert to ask questions. Here are practical steps you can take to preserve the facts.
- Write down a timeline: As soon as possible, write down everything you remember. Focus on when the relevant events occurred. Memory fades quickly, and these contemporaneous notes can be powerful evidence later.
- Keep a diary: If you are still in hospital, keep a daily log of who visited, what was said, and what the vital signs were (if you were told).
- Request the records: You have a legal right to access your (or your next of kin's) medical records under Freedom of Information or Data Protection acts.
- Do not delay: Because of the strict time limits, seek legal advice as soon as you suspect something went wrong. We can assist with the complex process of requesting and sorting the records.
FAQs
Is a delayed response always negligence?
No. Hospitals must prioritise patients based on urgency. If a doctor is delayed because they are treating another patient who is in immediate cardiac arrest, that may be considered a reasonable delay. Negligence arises when the delay is unreasonable or results from a failure to follow the system, such as ignoring a pager or understaffing.
What if staff recorded a high score but did not act on it?
This is a very strong indicator of a breach of duty. If the INEWS chart shows a "Red" score and there is no evidence that a doctor was called, or that treatment was escalated, it suggests the safety system was ignored. This is often the central evidence in a successful claim.
Do I have to make a formal complaint before seeking legal advice?
No. You can make a complaint to the HSE or the hospital directly, but this is a separate process from a legal claim. A hospital complaint investigation may give you some answers, but it cannot award compensation. You are free to seek legal advice before, during, or after a formal complaint process.
What happens if there is a Coroner's Inquest?
If a death was unexpected, the Coroner may hold an inquest. This is a public fact-finding inquiry. It does not blame anyone, but it establishes the medical cause of death. Our legal team often represents families at inquests to ask questions of the medical staff and establish if opportunities to intervene were missed.
Does the Patient Safety Act apply to private hospitals?
Yes. The requirements for Open Disclosure and the reporting of serious patient safety incidents apply to both public and private health service providers in Ireland. Private hospitals are not exempt from the duty of candour.
Expert investigation into medical care
When a patient deteriorates in hospital, the family is often left with unanswered questions. Was this inevitable? Or was there a window of time where a simple intervention could have changed everything?
At Michael Boylan LLP, we specialise in uncovering these answers. We have the medical and legal expertise to analyse the observation charts, interpret the INEWS scores, and identify the gaps in care. We approach every case with sensitivity and a determination to get to the truth.
If you believe a failure to monitor or escalate care has caused you or your family harm, please contact us. We will listen to your story, review the facts, and advise you on the best path forward.
Contact our team today for a confidential discussion.
*In contentious business, a solicitor may not calculate fees or other charges as a percentage or proportion of any award or settlement.
