First reported 17 Oct 2014•Latest report 8 Nov 2024
Definition
What this concern includes
Includes failures in hospital processes for recognising and managing patients who leave or may leave before clinical assessment, including temporary exit safeguards, assessment of capacity and risk, clear departure procedures, notification, escalation and arrangements for completing assessment or follow-up.
Not included
Excludes ordinary planned discharge or leave after the patient has received an adequate clinical assessment and the departure decision is appropriately managed.
Excludes general ward security, door-locking or patient-escape concerns where departure before clinical assessment is not the material safety condition.
Excludes failures in the quality of clinical assessment after the patient has remained safely available for assessment.
Excludes generic communication, staffing or documentation deficiencies unless they directly impair safeguards for a patient leaving before clinical assessment.
Reports
2
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
7
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.
NHS England2
Barts Health NHS Trust1
NHS Tower Hamlets Clinical Commissioning Group1
Northern Care Alliance NHS Foundation Trust1
Tredegar Practice1
Executive non-departmental public body2
NHS trust2
Clinical commissioning group1
Healthcare site1
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.
Manchester West
Concerns raised3
Failure to assess capacity to decide to leave hospital
Lack of clarity in the standard operating procedure for patients leaving hospital before clinical assessment
Delays in clinical assessment resulting in patients leaving hospital before assessment
This report raised 1 other concern. 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.7
Action
Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Action
Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Action
Develop and obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Action
Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
Action
Publish and implement the two-year delivery plan for recovering urgent and emergency care services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Action
Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Action
Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Lack of appropriate safeguards to prevent patients at risk from leaving before capacity assessment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures in hospital processes for recognising and managing patients who leave or may leave before clinical assessment, including temporary exit safeguards, assessment of capacity and risk, clear departure procedures, notification, escalation and arrangements for completing assessment or follow-up.
