Filter by topic
Filter by content type
  1. Home
  2. Resources

UK Paediatric Early Warning Systems (PEWS)

Quality improvement team
Save as PDF
Paediatric Early Warning Systems (PEWS) are designed to effectively recognise and respond to the deterioration of children or young people in a healthcare environment.

RCPCH is committed to supporting patient safety and improvement across the UK. We have collaborated with NHS England and the Royal College of Nursing to support the development and implementation of national PEWS for England through the System-wide Paediatric Observation Tracking (SPOT) programme.

This page has frequently asked questions about inpatient PEWS (launched in November 2023) and emergency department PEWS (launched in November 2026) in England. It also has summary information on the PEWS in Scotland and a link to our 2025 blog about PEWS in all four nations.
Status
Partnership
Last updated
Post date
18 September 2019
Table of contents
Contents

What is a PEWS?

PEWS stands for Paediatric Early Warning System. It is designed to support recognition of, and response to, deterioration in children and young people in healthcare settings. It typically includes an observation chart and a track-and-trigger score based on vital signs and clinical observations, linked to an escalation response. PEWS also supports the human factors involved in recognising and responding to deterioration, including communication, clear presentation of information, teamwork and organisational response.

Historically, PEWS has sometimes been used to refer only to a paediatric early warning score. In the System-wide Paediatric Observation Tracking (SPOT) Programme (see below for detail), PEWS refers to the whole system: the score, other triggers for concern, the escalation response and communication processes. Important: The numerical score supports clinical judgement; it does not replace it.

The below recording is from RCPCH Conference in May 2023 in Glasgow. Dr Linda Clerihew and Dr Sonia Joseph outlined the past experience and future plans for PEWS across Scotland. Professor Damian Roland provided an overview of progress with developing a standardised system for PEWS across England through the SPOT programme, while Sarah Scales and Rebecca Wood described their experiences participating in the pilot process for inpatient PEWS as part of the SPOT programme.

PEWS in Scotland, Wales and Northern Ireland

Scotland

The Scottish Patient Safety Programme (SPSP) Paediatric provides resources to support recognition of and response to deterioration in children and young people, including PEWS resources and educational webinars.

The programme is informed by the Essentials of Safe Care. Its 2023–2025 deteriorating child and young person collaborative was followed by planned review and redesign work, including a review of PEWS governance and clinical application. Current resources and programme information are available from Healthcare Improvement Scotland. Further details of these programmes can be found on these links:

Other nations

In May 2025, we published a spotlight blog on PEWS in all four UK nations, including Wales and Northern Ireland.

The following are FAQs about PEWS, both inpatient and emergency department, in England.

1. How can you get involved or raise queries?

You can find information about SPOT on the FutureNHS platform. You'll need to log in, and if you don't yet have an account, follow the links to register with an NHS email address.

For questions about the programme or to get involved, contact the National SPOT team at england.pews@nhs.net.

For questions about the College's role in the SPOT programme, contact qips@rcpch.ac.uk.

2. What is SPOT?

SPOT stands for System-wide Paediatric Observation Tracking. It aims to improve recognition of and response to deterioration in children and young people across healthcare settings. The programme is led by NHS England and supported and endorsed by RCPCH and the Royal College of Nursing (RCN).

Our ambition is to develop a consistent approach and common language to promptly recognise and respond to the acutely ill or deteriorating infant, child or young person. A paper was published in October 2020 on details of a pre-implementation survey conducted by the programme team for a standardised approach to paediatric early warning systems. In January 2021, the case for change was published in Archives of Disease in Childhood.

National inpatient PEWS charts were published in November 2023. 

National emergency department (ED) PEWS charts were published in November 2026. 

3. Which organisations are involved in the SPOT partnership? 

RCPCH is collaborating with NHS England and the Royal College of Nursing to support the development and implementation of national inpatient and ED PEWS for England. PEWS within other settings, including ambulatory services, mental health services and community settings are being developed in future phases of the programme. 

Led by the NHS England Children and Young People’s Transformation Team, the System-wide Paediatric Observations Tracking (SPOT) programme launched in 2020, with a programme of research, collaborative development of systems for inpatient PEWS and development of an eLearning suite to support implementation. 

The Partnership recognises the complexities in developing and implementing new clinical systems, including the challenges of integrating and decommissioning existing tools and the importance of ensuring patient safety and quality of care.

RCPCH continues to support and endorse the work being carried out by NHS England to lead and implement PEWS as part of the SPOT programme.

4. What is the background to SPOT?

Previous work to improve the recognition and response to deterioration in children and young people has rightly focused on improving the whole system response rather than the single component of measurement of observations.

Before national standardisation, hospitals across England used different local PEWS. This variation created challenges for consistent practice, shared learning and staff moving between organisations. National inpatient and ED PEWS have since been developed to support a common approach.

Many acute hospitals have developed their own programmes to improve the recognition and response to deterioration. These have included paediatric early warning scores (PEWS), initiatives and technology for improving the accuracy of taking and recording observations, and the timely escalation of care.

Development across different geographies and clinical settings has created inconsistencies across England. This is unlike other countries, including the devolved nations of Scotland and Northern Ireland, where single PEWS systems for children are in place.

In June 2018, NHS England & NHS Improvement, RCPCH and the Royal College of Nursing (RCN) came together to establish a joint National PEWS Programme Board for England. In 2020, the NHS SPOT (System-wide Paediatric Observations Tracking) Programme was launched, led by the NHS England Children and Young People’s Transformation Programme team.

5. What are the national PEWS charts?

National PEWS charts are available for inpatient wards and emergency departments. They build on research, clinical testing and collaborative development supported by the SPOT programme board. Charts, implementation resources and details of the Community of Practice are available through the FutureNHS platform.

National inpatient PEWS charts were published in November 2023. National emergency department (ED) PEWS charts were published in November 2026, and an ED PEWS eLearning module is due in December 2026.

6. How does national ED PEWS differ from inpatient PEWS?

The ED and inpatient systems share the same principles of combining observations with caregiver concern, specific concerns and clinical judgement to inform escalation levels and response.

The inpatient charts support ongoing ward-based monitoring. ED PEWS uses setting-specific assessment and escalation guidance that takes account of acuity. Blood pressure does not contribute to the numerical ED score, unlike the inpatient score; measurement should follow clinical indications and current guidance. The standard ED chart also includes a neurological assessment.

Both systems incorporate caregiver concern. The exact question and recording requirements should follow the current chart version; see FAQ 10.

7. When should a child move from ED PEWS to inpatient PEWS?

There is no single national standard for the point of transition to inpatient PEWS. A suggested approach is either when the decision to admit has been made but the child is awaiting ward transfer, at the discretion of a senior clinician or after four hours within the department. 

Organisations should agree and communicate a local protocol so that observation and escalation remain continuous during transfer of care.

8. Is there a digital version of PEWS?

An inpatient digital specification was published alongside the paper charts. The FutureNHS SPOT workspace provides specification documents and implementation resources. Trusts should confirm the current specification and version with the national team rather than assuming that the original beta documents remain current.

The longer-term ambition is that the ED NPEWS will a digital tool and that the age banded paper charts will be merged is to a single interface. However, as it will take time for Trusts to integrate the ED NPEWS into their EPR/ Medical Information Systems, the paper charts are an interim approach. 

9. Why do we need a standardised PEWS?

The RCPCH’s 2014 review of child mortality identified concerns about UK outcomes compared with other European countries. The reasons are multifactorial. Case reviews and national reports have also identified failures to recognise and respond to deterioration as a contributor to avoidable harm.

PEWS is one part of a wider safety system, not a standalone solution. Standardisation aims to support consistent assessment, communication, escalation and staff training. The 2021 Case for change paper explains this rationale and the limitations of the evidence available at that time. Full references are listed in FAQ 24.

10. How are concerns from parents, carers and young people recorded and acted on?

The voices of children, young people, parents and carers are an essential part of recognising deterioration. National inpatient and ED PEWS include a structured way to record their concerns and use those concerns to inform escalation. 

Staff should ask the caregiver question before the clinical assessment. At the initial assessment ask, “How is your child different since the decision to bring them here?” At subsequent assessments ask, “How is your child different since I last saw them?” Record the response as worse (W), better (B) or the same (S); asleep (A) and unavailable (U) can also be recorded.

Caregiver concern is an independent risk factor and can justify escalation even when the numerical PEWS score is low. The 13+ chart also allows the young person’s account of their wellbeing to be recorded.

11. How does Martha’s Rule align with the national inpatient and ED PEWS?

National PEWS supports the principles of Martha’s Rule by giving the concerns of children, young people, parents and carers a visible, structured place in assessment and reassessment. However, recording concern within PEWS is not the same as providing the separate rapid-review access required by Martha’s Rule. Organisations need both appropriate PEWS escalation processes and local Martha’s Rule arrangements.

Caregiver concern can trigger escalation independently of the numerical score. NHS England’s September 2026 ED Marthas Rule implementation letter extends Martha’s Rule to emergency departments, with implementation expected by the end of March 2028.

12. How is SPOT being evaluated?

Ongoing evaluation is taking place for the inpatient PEWS and wider early warning systems work. The evaluation will include understanding how best to capture parent concern and as a key focus and will look at the impact of the national PEWS implementation.

RAND Europe and THIS Institute published a qualitative study in June 2026 examining the transition from existing PEWS to the standardised national inpatient system across four hospitals. It identified staff confidence and commitment, training, leadership, peer support and local practical arrangements as important influences on implementation. This study informs how the system can be introduced successfully; it does not establish its impact on clinical outcomes.

In November 2026, NHS England reported that hospitals adopting national inpatient PEWS had consistently lower cardiac-arrest rates. The announcement does not provide sufficient methodological detail to establish whether PEWS caused this difference. The published implementation study should not be described as a commissioned evaluation of the clinical impact of the national rollout.

A 2024 retrospective study at Great Ormond Street Hospital assessed the SPOT PEWScore against emergency calls and unplanned intensive care admissions. It evaluates the numerical score in one specialist hospital, not the complete national system or its rollout.

13. What support is available to trusts and staff implementing national PEWS?

Support includes the national Community of Practice, local PEWS leads and national e-learning. NHS England encourages clinical, educational and strategic leads supporting ED implementation to join the Community of Practice. The ED e-learning module is due in December 2026; staff should complete it before using the national ED charts, alongside any additional local training.

The FutureNHS platform provides charts, implementation resources and information about the Community of Practice for the national Paediatric Early Warning System.

14. What does the national inpatient PEWS chart contain?

ED scoring differs, particularly in its treatment of blood pressure; see FAQs 21–23. The national inpatient PEWS chart contains:

  • a numerical score based on heart rate, respiratory rate, respiratory distress, blood pressure, oxygen saturation, oxygen delivery and capillary refill time (CRT)
  • other observations that do not contribute to the numerical score, including temperature, consciousness using AVPU (alert, responds to voice, responds to pain, unresponsive) and pain score
  • a caregiver or young person’s concern trigger
  • a clinical intuition trigger.

The inpatient chart has four named escalation levels: low, medium, high and emergency. Escalation can be triggered by the numerical score, consciousness level, caregiver or young person’s concern or clinical intuition. These inpatient categories should not be confused with the five acuity levels described for ED triage.

This allows a child to have a low PEWS score but the nurse reviewing them to escalate on their level of concern alone. It also allows parents to have an independent role if they are concerned about their child.

The following are FAQs specific to national ED PEWS:

15. What is national ED PEWS and why has it been developed?

National ED PEWS is the emergency department version of the national Paediatric Early Warning System. It standardises documentation of observations, recognition of deterioration and escalation of concerns for children and young people attending ED. The chart age bands are described in FAQ 20.

National ED PEWS supports rapid recognition and decision-making across the range of acute presentations seen in emergency departments. ED charts are available in A4 and A3 formats.

16. How should ED PEWS be used alongside existing triage and acuity systems?

ED NPEWS is intended to complement, rather than replace existing triage and acuity processes. A child will usually receive a primary assessment on arrival, focused on acuity and prioritisation. A secondary assessment then usually includes history-taking, vital signs and an initial ED NPEWS review to supports the recognition and monitoring of physiological deterioration.

Organisations should consider how ED PEWS is incorporated alongside their existing approach to initial assessment and prioritisation, including how the two are presented within digital systems. NPEWS provides the information to deliver a triage and acuity system but an existing triage model (Such as MTS or ESI) can also directly link with it.

Table 1. Acuity levels 1-5 map against the five PEWS escalation levels:

Acuity Level Escalation level 
5None
4Low
3Medium
2High 
1Emergency

Table footnote: The numbers 1-5 are made up of pre-defined clinical criteria (either via the NPEWS acuity model or as per any local triage system) and the NPEWS escalation categories are made up of the NPEWS score, clinical intuition, caregiver concern and assessment of pain/behaviour and alertness.

17. Which age groups are covered by the ED PEWS charts?

There are four age banded paper-based ED NPEWS charts: 0 to 11 months, 1 to 4 years, 5 to 12 years, or 13 years and over (up to 18 years) identified by the chart icon and header colour. The age bands reflect physiological changes through childhood therefore the correct age-band chart must be used for the child or young person being cared for.

18. Why is blood pressure not part of the national ED PEWS score?

Blood pressure is recorded on the ED chart but does not contribute to the ED PEWS score. Children with minor illness or injury do not always need a blood pressure measurement and readings can be falsely elevated because of stress or anxiety in the ED. A nurse or clinician with paediatric experience should ensure blood pressure is measured when clinically indicated, for example for a head injury or headache. Blood pressure should still be interpreted in the clinical context.

19. Which observations contribute to the numerical ED PEWS score?

The numerical score is based on respiratory rate, respiratory distress, oxygen saturation, oxygen requirement, heart rate and capillary refill time. Each parameter is plotted against age-specific ranges. A white box scores 0, yellow scores 1, orange scores 2 and pink scores 4.

20. What is recorded on the ED chart but does not contribute to the numerical score?

The chart also records caregiver concern, AVPU or GCS, blood glucose, temperature, a new suspicion of sepsis or septic shock, clinical intuition and blood pressure. These elements are not secondary to the numerical score. They help clinicians recognise risk that may not yet be reflected in the physiological observations and may independently prompt escalation.

21. How should the ED escalation guidance be used?

The escalation guidance should be used alongside the child’s initial acuity, clinical presentation, caregiver concern, specific concerns, behaviour, clinical intuition and numerical PEWS score.

Use the action grid on the reverse of the chart to record that a clinical assessment has been completed and when care has been escalated. Mark “E” when escalating care, or “P” when a patient care plan has been put in place. Follow local arrangements for the responding teams and document the action taken.

22. Are other variants of the national ED PEWS chart available?

The standard chart is suitable for most circumstances and includes a neurological assessment with Glasgow Coma Scale, pupillary reaction and limb movement. 

Three variants are also available on the FutureNHS SPOT workspace: an ED-with-admission chart, an ED-only chart and an inpatient PEWS chart for use in ED. The ED-with-admission and ED-only variants replace the neurological assessment on the reverse with standardised escalation guidance. The ED-only chart does not separate initial and ongoing observations. The inpatient-for-ED variant is for a child being cared for as an inpatient in ED, for example when no ward bed is available.

23. Where can I access further training on ED PEWS?

The national ED PEWS e-learning module is due on the NHS Learning Hub in December 2026. NHS England states that staff should complete it before using the national ED charts, with additional local training as needed. The draft training audience includes the following staff groups:

  • Emergency Nurse Practitioners (ENPs)
  • Advanced Nurse Practitioners (ANPs)
  • Advanced Care Practitioners (ACPs)
  • Extended Scope Physiotherapists (ESPs)
  • Physician Associates (PAs)
  • F1 and F2 doctors
  • CT1–2 doctors
  • CT3 doctors in Emergency Medicine.  
  • Resident Doctors ST4+ for both Emergency Medicine and Paediatrics

24. What other resources might be of interest?