Recurring concern
Unreliable postoperative clinical review and complication response
- Reports that mention this concern
- 5
- Times this concern has been raised
- 6
- Stated actions linked to this concern
- 8
What this concern includes
Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable postoperative clinical review and complication response’ and satisfy this evidence boundary: Cross-tranche review found that proposal 321 describes the same postoperative review-and-response process and shares assertion concern-assertion-794241924858603818163f65. Retain position 268 as the canonical proposal, broaden only enough to include the two directly supported routine postoperative-review assertions from position 321, and merge all non-duplicate direct memberships from both proposals.
What is not included
- Excludes general wound management unrelated to a recent surgical procedure.
- Excludes pre-operative assessment, intra-operative technique and routine post-operative care where no failure to monitor or respond to a possible surgical complication is identified.
- Excludes failures in treatment after a post-surgical complication has been reliably detected and appropriately escalated.
- Excludes generic clinical communication, documentation or staffing deficiencies unless they directly impair monitoring or response to a post-surgical complication.
- Excludes manifestations outside the manually reviewed boundary: Cross-tranche review found that proposal 321 describes the same postoperative review-and-response process and shares assertion concern-assertion-794241924858603818163f65. Retain position 268 as the canonical proposal, broaden only enough to include the two directly supported routine postoperative-review assertions from position 321, and merge all non-duplicate direct memberships from both proposals.
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 5 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to ensure specialist bariatric team review of post-operative gastric bypass patients
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Portsmouth Hospitals University NHS 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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Portsmouth Hospitals University NHS Trust
Implement a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
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Portsmouth Hospitals University NHS Trust
Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
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Portsmouth Hospitals University NHS Trust
Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
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Concerns raised1
Failure to ensure follow-up by the operating orthopaedic team for complications at the surgical site
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Cornwall Partnership NHS Foundation Trust
- Royal Cornwall Hospitals NHS Trust
- University Hospitals Plymouth NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Transfer to Derriford Hospital was correct because urgent assessment was required and it provided the closest prompt access to acute care.
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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Community-based care and transfer to Liskeard were appropriate because there was no urgent need for orthopaedic revision surgery.
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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust and University Hospitals Plymouth NHS Trust
Further liaison with the Royal Cornwall Hospitals orthopaedic team was not clinically needed until around the later transfer period.
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Concerns raised2
Failure to seek surgical opinion for suspected post-surgical symptoms
Failure to recognise post-surgical pain or sickness as indicators of serious complications
This report raised 6 other concerns. 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.
-
Concerns raised1
Failure to inspect the surgical wound
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The 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
-
The Trust
Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.
-
The Trust
Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.
-
The Trust
Review wound-care documentation, care plans and wound-assessment standards.
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The Trust
Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.
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The Trust
Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.
-
Concerns raised1
Failure to monitor and respond promptly to postoperative neck and facial swelling
This report raised 4 other concerns. 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026