First reported 14 Apr 2014•Latest report 12 Nov 2024
Definition
What this concern includes
Includes failures of transplant-specific clinical guidance and protocols, including their development, completeness, accessibility, dissemination, staff understanding and application, across kidney, heart or other named transplant-care contexts where the guidance is intended to direct safe assessment, treatment or perioperative care.
Not included
Excludes generic clinical-guideline awareness or access failures where no transplant-specific guidance is involved.
Excludes failures in transplant treatment, monitoring, medication or surgery where no deficiency in transplant-specific guidance is identified.
Excludes organ-specific clinical guidance unrelated to transplantation, and non-transplant guidelines even when they concern similar clinical decisions.
Excludes generic staffing, training, communication or governance deficiencies unless they directly impair transplant-specific clinical guidance.
Reports
2
Distinct published reports
Individual concerns
2
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
8
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.
Department of Health and Social Care1
George Eliot Hospital NHS Trust1
Medicines and Healthcare products Regulatory Agency1
NHS England1
The British Transplantation Society1
The Renal Association1
University Hospitals Coventry and Warwickshire NHS Trust1
Executive non-departmental public body1
Medicines and medical devices regulator1
Ministerial department1
NHS trust1
Registered charity1
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.
Coventry and Warwickshire
Concerns raised1
Lack of consistent awareness of and access to kidney transplant care guidelines and protocols
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 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.8
Action
Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Place the agreed renal-care guidelines on the Trust intranet after governance ratification.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 November 2024.
Action
Complete ratification and upload the renal management guidelines to the Trust intranet.
Stated by George Eliot Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2024.
Action
Produce laminated quick-reference guidance for managing acutely unwell kidney transplant recipients.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Disseminate the renal guidelines and quick-reference materials to Directorate Governance Leads, doctors, consultants and relevant clinical staff.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Discuss the new renal guidance at Directorate Governance Meetings and Trust-wide Governance meetings.
Stated by George Eliot Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 November 2024.
Action
Reiterate the renal guidance at the Doctors Grand Round.
Stated by George Eliot Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 November 2024.
Action
Display laminated renal quick-reference posters across clinical areas and the Trust.
Stated by George Eliot Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Specialist-led care is considered sufficient, so clinicians should not necessarily need to refer to renal care guidelines.
Stated by The British Transplantation Society and UK Kidney Association (UKKA; formerly the Renal AssociationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Stated by University Hospitals Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Specialist renal care should rely on direct specialist contact rather than universal guideline access, because guidelines may cause misunderstanding of urgency.
Stated by University Hospitals Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester West
Concerns raised1
Lack of protocols and guidelines for perioperative management of heart transplant patients undergoing non-cardiac surgery
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.
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 of transplant-specific clinical guidance and protocols, including their development, completeness, accessibility, dissemination, staff understanding and application, across kidney, heart or other named transplant-care contexts where the guidance is intended to direct safe assessment, treatment or perioperative care.
