Recurring concern
Failure to maintain safe care and support during service transitions
Pin
Get email alerts
Request correctionFirst reported 26 Nov 2014•Latest report 23 Jun 2025
What this concern includes
Includes failures of end-to-end care and support continuity during service, accommodation, funding or level-of-care transitions, including inadequate transition planning, loss of funding, missing alternative arrangements, failure to accommodate identified risks and needs, and unclear responsibility for maintaining support.
Not included
- Excludes routine care-continuity failures where no service, accommodation, funding or level-of-care transition is involved.
- Excludes failures confined to a named discharge, referral, placement or mental-health pathway when that pathway supplies the more specific supported boundary.
- Excludes generic funding, staffing, communication or care-planning deficiencies unless they directly disrupt safe care or support during a transition.
- Excludes failures in the quality of care after a transition where the transition and continuity arrangements themselves were adequate.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2014–2025
- Stated actions
- 11
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.
-
Concerns raised1
Failure of step-down and discharge systems to facilitate identified risks and needs
This report raised 8 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
-
Action
Operate a discharge facilitation team comprising network navigators, discharge coordinators and a team manager to reduce nursing administrative workload.
Stated by North London NHS Foundation Trust -
Action
Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.
Stated by North London NHS Foundation Trust -
Action
Continue developing a cross-ward approach to PICU step-down through a women’s PICU workshop and planned care-group structure.
Stated by North 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
-
Position
Severe bed-capacity pressures mean step-down from PICU cannot currently be planned in the way ideally required.
Stated by North London NHS Foundation Trust
-
Concerns raised1
Failure to actively reconsider discharge safety when arrangements change
This report raised 8 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
-
Action
Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
Stated by Essex Partnership University NHS Foundation Trust
-
Action
Complete a thematic review of inpatient deaths to inform discharge safety improvements.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
Stated by Essex Partnership University NHS Foundation Trust
-
Concerns raised1
Failure to maintain continuity of inpatient care during ward moves
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 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
Lack of a step-down process for ad hoc waking night cover
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 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
-
Action
Implement a documented step-down process requiring safety planning with the social worker before reducing or removing ad hoc waking-night support.
Stated by United Children's Services (United Health
-
Concerns raised1
Failure to maintain adequate wound inspections and dressing changes when diabetic foot clinic attendance changes
This report raised 4 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
-
Action
Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.
Stated by Tower Bridge Care Centre -
Action
Review each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.
Stated by Tower Bridge Care Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
There is no evidence that clinic attendance was less frequent than clinically indicated or reduced because of the Covid-19 pandemic.
Stated by King'S College Hospital NHS Foundation Trust
-
Position
The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.
Stated by Tower Bridge Care Centre
-
Concerns raised1
Failure to maintain continuity of funding when required paperwork cannot be completed or understood independently
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 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 to maintain adequate support during moves, funding changes and step-down of services
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The step-down placement was clinically appropriate because Miss Hawkins was assessed as able to maintain her safety without further assistance.
Stated by Dudley Integrated Health and Care NHS Trust
Data last updated 7 September 2026