First reported 4 Oct 2013•Latest report 17 Jun 2025
Definition
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.
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.
Reports
24
Distinct published reports
Individual concerns
27
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
35
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.
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
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.
Surrey
Concerns raised2
Lack of consultant ward rounds in weekend urology on-call arrangements
Delays in urology review of emergency admissions
This report raised 17 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.2
Action
Provide weekend urology review and supervision through consultant ward rounds, registrar emergency assessments, case discussion and consultant availability.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 July 2014.
Action
Review the three-hospital urology on-call services and develop an action plan toward seven-day compliance.
Stated by Frimley Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 July 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
No specific national urology on-call guidelines existed; the cited recommendations were recent and not yet fully implemented.
Stated by Frimley Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing weekend arrangements provide registrar and consultant review of urology emergency admissions and inpatients.
Stated by Frimley Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing arrangements provide safe, supervised out-of-hours trainee practice through registrar discussions and consultant advice or review when required.
Stated by Frimley Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Consultant-delivered emergency services with regular inpatient ward rounds require additional consultant appointments before compliance can be achieved.
Stated by Frimley Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner South London
Concerns raised1
Lack of consultant physician input into management of in-patients with physical health problems
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 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.
Berkshire
Concerns raised2
Delays in medical review of admitted patients
Delays in medical review of admitted patients
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 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.3
Action
Introduce a hospital referral procedure covering Emergency Department referrals.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2014.
Action
Implement electronic Smartphone referral notifications with Specialist Registrar allocation and a one-hour inpatient-team review goal.
Stated by Frimley Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2014.
Action
Establish a 24-hour Central Hub with patient tracking, referral and bleep management, workload oversight, handover, task allocation, escalation and senior-manager staffing.
Stated by Frimley Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2014.
Cornwall
Concerns raised1
Lack of a time threshold for doctor review and assessment of GP-referred hospital admissions
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 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 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.
