First reported 4 Sep 2013•Latest report 23 Oct 2025
Definition
What this concern includes
Includes failures in the outpatient-appointment process involving tracking whether appointments are due or attended, arranging or rebooking required appointments, ensuring follow-up occurs within a safe timeframe, and maintaining appointment status across discharge or other care transitions.
Not included
Excludes failures in psychiatric, specialist, cancer or other separately named appointment pathways where that narrower process provides the more specific supported boundary.
Excludes generic case monitoring or referral tracking where no outpatient appointment is the material object.
Excludes transport failures that prevent attendance when the outpatient appointment process itself was reliably arranged and tracked.
Excludes clinical shortcomings during an appointment after the patient has been seen.
Reports
10
Distinct published reports
Individual concerns
10
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
17
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Central and North West London NHS Foundation Trust1
Department of Health and Social Care1
High Down Prison1
Ministry of Justice1
NHS England1
Priory Group1
Royal Devon University Healthcare NHS Foundation Trust1
Somerset NHS Foundation Trust1
St Giles1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Priory Hospital Altrincham1
The Priory Hospital Roehampton1
the Shrewsbury and Telford Hospital NHS Trust1
University Hospitals Birmingham NHS Foundation Trust1
University Hospitals of Leicester NHS Trust1
NHS trust6
Healthcare site2
Ministerial department2
Domiciliary care provider1
Executive non-departmental public body1
Independent healthcare provider1
Prison or young offender institution1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to arrange cardiology follow-up after discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Stated by the Shrewsbury and Telford Hospital NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised1
Delays in outpatient follow-up for ear infections
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Monitor the ENT waiting list through daily oversight, weekly tracking meetings and fortnightly booking and operational reviews, with activity changes discussed to address demand.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Strengthen ENT outpatient follow-up monitoring through booking validation, waiting-list dashboards, overdue-date tracking, additional booking-office staffing and routine capacity reviews.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Use the EPR fast-pass system to offer suitable vacant outpatient slots to patients through the MyCare application.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Introduce virtual ticket scheduling through MyCare, with appointment notifications, patient self-booking and letters for patients without the application.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing ENT waiting-list monitoring and patient-service correspondence are considered sufficient for effective outpatient follow-up.
Stated by Somerset NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Enhanced booking validation, waiting-list monitoring, staffing and electronic scheduling are considered sufficient to monitor ENT outpatient follow-ups efficiently.
Stated by Royal Devon University Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner West London
Concerns raised1
Failure to arrange follow-up appointments before discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Action
Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 10 March 2023.
Action
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023.
Staffordshire South
Concerns raised1
Lack of tracking systems for non-cancer outpatient appointments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Failure to arrange an outpatient appointment within 3 weeks of discharge
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Formulate and implement guidelines for conservatively managed potentially unstable fractures, including follow-up and X-ray review timescales.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 February 2018.
Action
Create three daily hot-clinic slots to provide capacity for expedited post-discharge Trauma and Orthopaedic follow-up.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
Manchester South
Concerns raised1
Failure to ensure follow-up appointments are booked before discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure to effectively follow up patients who miss pre-booked clinical appointments
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Operate and share the In-Reach DNA procedure, including same-day follow-up, risk review and rebooking after missed appointments.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Manchester West
Concerns raised1
Failure to discharge patients after repeated missed appointments within defined timescales
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Require independent doctors to send discharge letters to GPs and relevant professionals after final non-attendance contact, copying patients and including medication, aftercare and crisis actions.
Stated by Priory Group Healthcare DivisionStated completedThe respondent said that this action was complete when they made their response on 9 October 2015.
Action
Notify Hospital Medical Directors of the revised requirements and require routine discussion of patient discharge during independent doctors’ supervision and appraisal.
Stated by Priory Group Healthcare DivisionStated completedThe respondent said that this action was complete when they made their response on 9 October 2015.
Manchester South
Concerns raised1
Failure to schedule outpatient appointments compatibly with patients' existing therapy commitments
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Failure to arrange the patient's next outpatient appointment
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Patients may appropriately arrange their own outpatient appointments where clinical circumstances permit, alongside existing discharge and information-sharing arrangements.
Stated by University Hospitals of Leicester NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures in the outpatient-appointment process involving tracking whether appointments are due or attended, arranging or rebooking required appointments, ensuring follow-up occurs within a safe timeframe, and maintaining appointment status across discharge or other care transitions.
