Recurring concern
Failure to maintain safe care and support during service transitions
- Reports that mention this concern
- 7
- Times this concern has been raised
- 7
- Stated actions linked to this concern
- 11
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- North London NHS Foundation Trust
Stated actions 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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North London NHS Foundation Trust
Operate a discharge facilitation team comprising network navigators, discharge coordinators and a team manager to reduce nursing administrative workload.
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North London NHS Foundation Trust
Implement the Perfect Day model with standardized ward timetables, daily electronic handover templates and documentation of multidisciplinary and observation decisions.
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North London NHS Foundation Trust
Continue developing a cross-ward approach to PICU step-down through a women’s PICU workshop and planned care-group structure.
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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North London NHS Foundation Trust
Severe bed-capacity pressures mean step-down from PICU cannot currently be planned in the way ideally required.
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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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions 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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Essex Partnership University NHS Foundation Trust
Assign Family Ambassadors to support family engagement, information sharing and recording family information for multidisciplinary consideration.
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Essex Partnership University NHS Foundation Trust
Invite the appropriate Home Treatment Team to attend ward reviews on the day of discharge.
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Essex Partnership University NHS Foundation Trust
Assign a registered nurse to coordinate each patient’s safe-discharge preparation, travel, support, follow-up and crisis-contingency plans.
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Essex Partnership University NHS Foundation Trust
Complete a thematic review of inpatient deaths to inform discharge safety improvements.
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Essex Partnership University NHS Foundation Trust
Mobilise the new inpatient operating model and its implementation plan for proactive, safe and effective discharge across adult and older-adult wards.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- United Children's Services (United Health
Stated actions 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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United Children's Services (United Health
Implement a documented step-down process requiring safety planning with the social worker before reducing or removing ad hoc waking-night support.
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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.
Linked responses
- King'S College Hospital NHS Foundation Trust
- Tower Bridge Care Centre
Stated actions 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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Tower Bridge Care Centre
Continue participating in monthly multidisciplinary meetings with clinical, social care, mental health, palliative care and pharmacy professionals.
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Tower Bridge Care Centre
Review each resident’s clinical risks through monthly Key Clinical Indicators exception reports, including wounds and escalation processes.
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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King'S College Hospital NHS Foundation Trust
There is no evidence that clinic attendance was less frequent than clinically indicated or reduced because of the Covid-19 pandemic.
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Tower Bridge Care Centre
The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.
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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.
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 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.
Linked response
- Dudley Integrated Health and Care NHS 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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Dudley Integrated Health and Care NHS Trust
The step-down placement was clinically appropriate because Miss Hawkins was assessed as able to maintain her safety without further assistance.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026