Failure to provide timely medical review of admitted patients
First to latest report 4 Oct 2013 — 17 Jun 2025
Reports that mention this concern
24
Times this concern has been raised
27
Stated actions linked to this concern
35
What this concern includes
Includes failures of the inpatient medical-review process involving absent, delayed or insufficiently timely review of admitted or transferred patients, including review prompted by clinical observations, deterioration, presenting symptoms or a request from ward staff.
What is not included
Excludes delays limited to consultant review where the broader medical-review process is not deficient.
Excludes nursing observations, monitoring or escalation failures when no failure to provide medical review is identified.
Excludes generic staffing, documentation, communication or handover deficiencies unless they directly result in absent or delayed medical review of an admitted patient.
Excludes outpatient, community or non-inpatient clinical reviews.
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.
University Hospitals Sussex NHS Foundation Trust3
Recipient name withheld2
Royal Sussex County Hospital2
Barts Health NHS Trust1
Blackpool Teaching Hospitals NHS Foundation Trust1
Calderdale and Huddersfield NHS Foundation Trust1
Coroners' Society of England and Wales1
Department of Health and Social Care1
Derbyshire Community Health Services NHS Foundation Trust1
East Midlands Ambulance Service NHS Trust1
Faculty of Intensive Care Medicine1
Frimley Health NHS Foundation Trust1
Healthcare Safety Investigation Branch1
Heatherwood and Wexham Park Hospitals NHS Foundation Trust1
Medicines and Healthcare products Regulatory Agency1
NHS trust16
Healthcare site10
Type not available2
Executive non-departmental public body1
Health professional body1
Medicines and medical devices regulator1
Ministerial department1
Multi-service care provider1
Professional membership body1
Registered charity1
Reports and published responses 24 reports
See individual reports that have raised this concern, and the actions taken in response
South Yorkshire (Eastern)
Concerns raised1
Delays in medical review following an inpatient fall
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham 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
the Rotherham NHS Foundation Trust
Expand resident-doctor induction content on responding to deteriorating patients and prioritise overnight reviews for clinically deteriorating patients.
the Rotherham NHS Foundation Trust
Move towards employing two medical registrars on call overnight.
the Rotherham NHS Foundation Trust
Review national inpatient-falls audit data and share findings and improvement actions for qualifying injured inpatients.
Essex
Concerns raised1
Delays in medical review due to doctor staffing levels
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Mid and South Essex 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.2
Mid and South Essex NHS Foundation Trust
Implement changes and processes to ensure patients are properly informed of their imaging results.
Mid and South Essex NHS Foundation Trust
Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Mid and South Essex NHS Foundation Trust
NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Hampshire, Portsmouth and Southampton
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
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.
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.
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.
Derby and Derbyshire
Concerns raised1
Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to escalate clinically significant melaena for timely medical review
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Whittington Health 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.2
Whittington Health NHS Trust
Provide deteriorating-patient recognition and management training to ward nurses through the Critical Care Outreach Team.
Whittington Health NHS Trust
Introduce ward-nurse training on recognising and escalating gastrointestinal bleeding, led by the endoscopy nursing team.
Inner North London
Concerns raised1
Failure to ensure timely medical review after deterioration and repeated requests
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to provide senior clinician review after admission
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals of North Midlands 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.1
University Hospitals of North Midlands NHS Trust
Escalate cases without an enacted management plan to the Nurse in Charge or senior decision-maker and record the escalation in nursing documentation and Datix.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
University Hospitals of North Midlands NHS Trust
The absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised2
Failure to review patients and escalate care when EWS trigger points require it
Failure of registrars to review patients during ward visits
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care 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
Tameside and Glossop Integrated Care NHS Foundation Trust
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Tameside and Glossop Integrated Care NHS Foundation Trust
Implemented NEWS2, including revised observation and escalation processes and associated staff training.
Tameside and Glossop Integrated Care NHS Foundation Trust
Develop a triggered referral process to orthogeriatricians for patients requiring senior review.
Tameside and Glossop Integrated Care NHS Foundation Trust
Review and revise consultant job plans to support consultant ward-round availability, subject to management approval.
Tameside and Glossop Integrated Care NHS Foundation Trust
Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.
Norfolk
Concerns raised1
Failure to provide medical review after ward rounds
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.