When should a nurse escalate a deteriorating patient?
The short answer is: as soon as you have a reason to, and not later. In adult inpatient and ambulance settings in England, the National Early Warning Score 2 (NEWS2), published by the Royal College of Physicians, sets the minimum triggers. Your local escalation policy builds on it and names who you should call. Clinical concern is a reason to escalate on its own, whatever the score.
Most patients who have an unexpected cardiac arrest in hospital, or need an unplanned move to intensive care, show changes in their observations in the hours before. Their breathing gets faster, oxygen levels fall, blood pressure drops or they become confused. Harm usually happens not because nobody could have seen it, but because a link in the chain broke.
NEWS2 is designed for adults. It is not used for children, who are assessed with paediatric early warning scores, or in pregnancy, where maternity early warning scores apply. The principles in this guide still hold in every setting.
What NEWS2 score should you escalate?
NEWS2 scores seven parameters from 0 to 3: respiratory rate, oxygen saturation, whether the patient is on air or oxygen, systolic blood pressure, pulse, level of consciousness (ACVPU) and temperature. The total, and any single score of 3, decide the minimum response. The table summarises the RCP thresholds. Your trust's policy may set additional local triggers, so always know your own.
| NEWS2 result | Clinical risk | Minimum response |
|---|---|---|
| Total 0 | Low | Continue routine monitoring (at least 12-hourly) |
| Total 1 to 4 | Low | Registered nurse assesses and decides whether to increase monitoring or escalate |
| 3 in any single parameter | Low to medium | Urgent ward-based response: inform the medical team caring for the patient |
| Total 5 or 6 | Medium | Urgent review by a clinician competent in assessing acutely ill patients, at least hourly observations |
| Total 7 or more | High | Emergency response by a team with critical care skills, continuous monitoring |
Two points cause frequent problems. First, new confusion scores 3 on its own; never assume an older patient is always like this without checking with family, carers or earlier notes. Second, SpO2 Scale 2 is only for patients with confirmed hypercapnic respiratory failure and a prescribed target range, and the decision must be made and recorded by a competent clinician. Using it for the wrong patient can hide falling oxygen levels.
If a patient has signs of infection and is unwell or deteriorating, think sepsis. NICE guideline NG253 covers suspected sepsis in people aged 16 or over and uses NEWS2 alongside clinical judgement and risk factors. Follow your organisation's sepsis pathway.
How do you assess a deteriorating patient using ABCDE?
Resuscitation Council UK recommends the ABCDE approach. It gives you an order that deals with the most immediately dangerous problems first. Treat what you find as you go, call for help early, and reassess after any intervention.
- Airway: Can the patient speak? Listen for noisy breathing, stridor or gurgling. Call for help immediately if the airway is at risk.
- Breathing: Count the respiratory rate for a full minute, check saturations against the prescribed target, and look at effort and chest movement. Sit the patient up if appropriate and give oxygen as prescribed or per policy.
- Circulation: Pulse rate and rhythm, blood pressure, capillary refill, skin colour and temperature, urine output and any bleeding.
- Disability: Level of consciousness using ACVPU, any new confusion, blood glucose, pain, and medicines that cause drowsiness such as opioids.
- Exposure: Temperature, wounds, drains, rashes, calves and signs of infection, looking at the whole patient while preserving dignity.
Respiratory rate is the observation most often estimated or skipped, yet it is one of the earliest signs that something is wrong. A chart showing 18 at every set for three days should make you ask whether it was counted at all.
Listen to the patient and the people who know them. Phrases like 'she has gone quiet' or 'he is not himself' are clinical information. So is your own sense that something is not right.
How do you escalate using SBAR?
SBAR (Situation, Background, Assessment, Recommendation) makes your call short, clear and hard to brush aside. Have the observation chart, notes and medicines chart in front of you before you phone. End by confirming what has been agreed and by when.
Hi, it's the nurse on ward 7, sorry to bother you. Mrs A in bed 12 seems a bit off and her obs aren't great. Could you see her when you get a chance?
This is Grace, staff nurse on ward 7. I'm calling about Mrs A in bed 12, NEWS2 of 8, up from 2 four hours ago. She is 74, admitted yesterday with a urinary tract infection. Respiratory rate 26, saturations 93% on air, systolic 96, pulse 118, newly confused, temperature 38.6. I think she may be septic. As our policy requires for this score I have called the outreach team too. I need you to review her now. She is on oxygen to her target range and continuous monitoring. Can you confirm you are coming in the next few minutes?
The strong version gives the score and the trend, the key numbers, what the nurse thinks is happening, what has already been done and a specific request with a time. It also shows the nurse following the local policy for a high score rather than relying on a single call.
What should you do if the doctor does not come?
Escalating once is not always enough. If the person you call does not attend, does not attend in the time agreed, or gives advice you believe is unsafe, escalate further. Being polite matters, but patient safety comes before hierarchy, and the NMC Code expects you to act without delay if there is a risk to safety.
- Tell the nurse in charge straight away.
- Call the next person in your local chain, such as the registrar, consultant or critical care outreach team.
- Put out an emergency call if the patient's condition calls for it. You never need permission to do this.
- Keep monitoring at the frequency the score requires while you wait.
- Record each call: time, who you spoke to, what you said and what was agreed.
Why are observations missed and escalation delayed?
When something goes wrong, it is rarely one person's carelessness. Understanding the causes is the starting point for insight, and it helps you design safeguards for your own practice.
| Factor | How it shows up |
|---|---|
| Workload and staffing | Observations done late or in batches; high-risk patients missed among competing demands |
| Delegation without review | A healthcare assistant records a high score but the registered nurse does not see it for hours |
| Normalisation | A patient who 'always' runs a fast pulse, or a ward where high scores are common, stops prompting action |
| Hierarchy | Worry about bothering a busy doctor at night or being criticised for over-calling |
| Handover gaps | A concern raised on one shift is not passed on, so the next team starts from scratch |
| Documentation | An escalation is made but not recorded, so no one can tell what was agreed |
Naming these factors is not about shifting blame. A good reflection explains the pressures honestly and still accepts your own part, then shows what you now do differently when the same pressures come back.
Can a nurse be referred to the NMC for failing to escalate?
Yes. Concerns about assessment, observations and escalation are among the most common clinical concerns raised about nurses. Most are handled locally by the employer through investigation, support and retraining. A referral is more likely where there was serious harm, a pattern of repeated failings, a lack of improvement after support, or dishonesty, such as recording observations that were not taken.
Clinical concerns like these are generally seen as capable of remediation. A regulator looks at whether you understand what went wrong, have updated your knowledge and skills, and have since practised safely, ideally with evidence from other people.
Joseph, a staff nurse on a medical ward, planned four-hourly observations for an older woman with a chest infection whose NEWS2 was 4. At 02:00 a healthcare assistant recorded a set of observations giving a NEWS2 of 8, but Joseph did not see the chart until 04:30, when he found the patient drowsy and called the registrar. She was moved to a higher level of care and recovered. In his reflection Joseph did not blame the assistant. He accepted that he had delegated the observations without asking for high scores to be reported or checking the results, and that he had not told the nurse in charge his workload was unsafe. He completed deteriorating patient training, now agrees reporting thresholds with assistants at the start of every shift, checks each set of observations within 30 minutes, and his manager audited his charts over three months.
How should you document observations and escalation?
If it is not recorded, others cannot see it happened and cannot act on it. Good records protect the patient first and you second.
- Record observations at the time they are taken, with the NEWS2 score calculated and checked.
- Note the time of each escalation, who you contacted, what you reported and the plan agreed, including when the patient will be reviewed.
- Record the agreed observation frequency and the threshold for calling again.
- If you escalate further because a review has not happened, record that too.
- Never complete observations that were not done, and never alter an entry after the event. Add a dated, timed late entry instead.
Where can I build on this?
This guide is educational. Always follow your local escalation policy and current national guidance, and keep your skills up to date through accredited hands-on training in your workplace.
If you want to refresh these skills for revalidation, or you need to show learning after a concern about observations or escalation, our course Patient Assessment, Observations and Escalation works through ABCDE, NEWS2 scoring, SBAR, the human factors behind missed deterioration, and a guided reflection with a remediation plan. Related courses on medication errors and record keeping cover two areas that often sit alongside escalation concerns.
Frequently asked questions
What NEWS2 score requires escalation?
Under the Royal College of Physicians guidance, a score of 3 in any single parameter needs an urgent ward-based response and the medical team should be informed. A total of 5 or 6 needs an urgent review by a clinician skilled in acute illness, and 7 or more needs an emergency response from a team with critical care skills. Your local policy may add further triggers.
Should I escalate if the NEWS2 score is low but I am worried?
Yes. Clinical concern is a valid reason to escalate on its own. Early warning scores support judgement rather than replace it, and some patients, such as older people or those on beta blockers, deteriorate with only small changes in their observations. Explain clearly why you are worried and record the call.
What do I do if the doctor does not come to review my patient?
Escalate further using your local chain. Tell the nurse in charge, contact the registrar, consultant or critical care outreach team, and put out an emergency call if the patient's condition needs it. Keep monitoring and record every call, including the time, who you spoke to and what was agreed.
Is NEWS2 used for children or pregnant women?
No. NEWS2 is designed for adults aged 16 and over who are not pregnant. Children are assessed using paediatric early warning scores and pregnant or recently pregnant women using maternity early warning scores, in line with your local and national systems. The principles of structured assessment and escalation still apply.
Can I be struck off for failing to escalate a deteriorating patient?
Most concerns about escalation are dealt with locally through support and retraining. Referral to the NMC is more likely where there was serious harm, repeated failings or dishonesty. Clinical concerns are generally seen as remediable, and evidence of insight and safe practice matters. If you are under investigation, get advice from your union or defence organisation.
Who is responsible when a healthcare assistant takes the observations?
The registered nurse who delegates the task remains accountable for the decision to delegate and for reviewing the results. Agree at the start of each shift which scores must be reported to you immediately, and check delegated observations and their trend yourself within a set time.
What is SBAR in nursing?
SBAR stands for Situation, Background, Assessment and Recommendation. It is a structured way to pass on concerns about a patient so the person receiving the call quickly understands what is wrong and what you need. Finish by confirming what has been agreed and by when, then record it.
Related courses
Patient Assessment, Observations and Escalation
This course covers how to recognise and respond to a deteriorating adult patient using structured assessment, NEWS2 and clear escalation. It explains…
Medication Errors: Reflection and Remediation
This course explains why medication errors happen, what you must do when one occurs, and how to show a regulator or employer that you have understood…
Record Keeping and Documentation: Remediation Course
This course explains what good clinical documentation looks like, why record-keeping concerns arise, and why altering or falsifying a record is…
Sources and further reading
- National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS. Royal College of Physicians.
- The ABCDE approach. Resuscitation Council UK.
- Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). National Institute for Health and Care Excellence.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
- Martha's Rule. NHS England.
- Acutely ill adults in hospital: recognising and responding to deterioration. National Institute for Health and Care Excellence.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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