Recurring concern
Failure to escalate patient-safety concerns to senior oversight
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Request correctionFirst reported 27 Nov 2013•Latest report 6 Feb 2026
What this concern includes
Includes failures by clinical, care or operational staff and teams to recognise, report or escalate patient-safety concerns, significant care problems or serious safety matters promptly through the appropriate senior-staff or senior-management pathway.
Not included
- Excludes failures to act after a safety concern has already been escalated; those concern senior oversight response rather than upward escalation.
- Excludes escalation processes for non-safety matters, routine administrative issues or ordinary performance concerns.
- Excludes escalation within a separately named safety system or pathway when that system provides the more specific supported boundary.
- Excludes failures involving escalation of a clinical deterioration episode where the concern is solely obtaining immediate clinical treatment rather than reporting the underlying safety concern to senior oversight.
- Reports
- 14
- Individual concerns
- 15
- Date range
- 2013–2026
- Stated actions
- 20
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents
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 concernsEach 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.5
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Action
Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.
Stated by Torbay and South Devon NHS Foundation Trust -
Action
Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.
Stated by Torbay and South Devon NHS Foundation Trust -
Action
Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.
Stated by Torbay and South Devon NHS Foundation Trust
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Action
Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.
Stated by Torbay and South Devon NHS Foundation Trust -
Action
Commence quarterly learning events with incident reporting as a core topic.
Stated by Torbay and South Devon NHS Foundation Trust
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Concerns raised1
Failure to report omissions in important documentation to a senior colleague
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to bring issues of concern to the attention of hospital authorities
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to identify and escalate observation suspension in the 72-hour report
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.
Stated by North East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to escalate operational problems to the on-call manager
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to escalate recurring unsafe clinical waste disposal to senior managers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Position
Existing glove-disposal policies, staff awareness, safety checks, and the new PPE policy and checking system were considered sufficient responses.
Stated by Care Quality Commission
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Position
Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure to directly inform senior clinical staff of disclosed suicide risk
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 concernsEach 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
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Action
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Position
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised1
Lack of timely escalation of serious ED/ABD safety matters to senior management
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of junior staff to identify deterioration and escalate to senior staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.
Stated by University Hospitals Birmingham NHS Foundation Trust
-
Concerns raised1
Failure to escalate welfare incidents to the on-call senior manager
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Establish the Greater Manchester Responding to Crisis Board to oversee cascading, embedding and delivery of the response protocols.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
Stated by NHS Greater Manchester Integrated Care Board
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Action
Issue a memo to all staff increasing awareness of the requirement to seek support from on-call managers.
Stated by Pennine Care NHS Foundation Trust
Data last updated 7 September 2026