Safe system framework for children at risk of deterioration

This framework aims to improve recognising and responding to children at risk of deterioration. A safer system can work in partnership with families and patients, develop a patient safety culture and support ongoing learning.


RCPCH and NHS Improvement have developed this framework with clinicians and experts.

It provides a ‘state of the nation view’ that drives action and local services for infants, children and young people.

Four groups

  • Infants, children and young people, and their families
  • Clinicians and the wider team - including doctors, nurses, pathologists, pharmacists, radiologists
  • Local organisations and service providers
  • National organisations with leadership roles - such as NHS Improvement, NHS England, RCPCH, Royal College of Nursing, etc.

Six core elements

Each of the core elements is a particular aspect of the system. Follow the links to see the responsibilities and access resources.

1: Patient safety culture

A large and challenging element covering many aspects that all groups are now trying to define and develop, including a commitment to overall improvement in patient safety, prioritising safety, leadership and executive accountability, and monitoring and measuring patient safety

2: Partnerships with patients and families

While all of the core elements focus on the patient and family, this partnership is an area of increased growth and central to supporting all the others

3: Recognising deterioration

The ability to spot physiological deviations before significant changes in care are needed or harm occurs is a fundamental working element which is central to the system

4: Responding to deterioration

Ensuring a timely and accurate response encompassing all necessary support and treatment from all those involved in the care of the patient is the vital element that is often the key change required

5: Open and consistent learning

Consideration of the system errors and individual responsibility, recording, investigating and evaluating incidents as well as best practice in order to learn and effect change will drive forward continual improvements in all elements

6: Education and training

Consistently building clinical knowledge and capability as well as patient safety and improvement methods will provide the foundation for all elements to be enhanced

This image shows the six core elements and groups

Six core elements and groups of the safer system for children at risk of deterioration


Research shows that failure to recognise and treat patients whose condition is deteriorating is a cause of significant unintended harm in healthcare environments.

There are multi-factorial reasons why deterioration in children is missed. We can cluster these into themes:

  • systems failure
  • not responding to physiological changes (recognising and responding to deterioration)
  • parent and carer engagement (and working in partnership with patients and their families)
  • healthcare professionals training and education.

In 2015, NHS England created and collated resources based on these themes. The ReACT (Respond to Ailing Children Tool) aism to improve outcomes and reduce the incidence of deterioration in the acutely ill infant, child or young person.

Why an early warning system is needed

The National Reporting and Learning System (NRLS) receives information about patient safety incidents. This evidence suggests that the greatest potential for improvement lies within the whole system of recognition and response to deterioration, and not simply the measurement of a child’s observations. 

In other words, it is about an early warning system rather than an early warning score.

There have been recent moves towards the development and spread of a single Paediatric Early Warning System (PEWS) in Scotland, Northern Ireland and Republic of Ireland. These programmes should be closely looked at - to share learning and to consider what might be possible in the much larger healthcare system in England.

The PEWS Utilisation and Mortality Avoidance (PUMA) study is ongoing at the National Institute for Health Research (NIHR). This examines the features of both scores and systems and of other factors that may be implemented to improve the outcomes of harm, morbidity and mortality in children who deteriorate while they are inpatients.

Access the full resource

You can use the menu to access the six core elements of the resource.

Or, download the full resource (PDF, 886 KB).