First reported 4 Sep 2013•Latest report 15 Jun 2026
Definition
What this concern includes
Includes failures of the end-to-end patient-care continuity process, including unclear or unassigned responsibility, changing or excessive personnel, inadequate continuity between clinicians or services, and insufficient coordination that leaves care fragmented or without consistent oversight.
Not included
Excludes failures limited to a specific handover, record, referral or discharge control when continuity of patient care is not itself the shared unsafe condition.
Excludes generic staffing shortages, workload or turnover concerns unless they directly result in failure to maintain continuity of patient care.
Excludes continuity failures in non-patient processes, such as equipment, premises or administrative workflows.
Excludes failures belonging to a more specific named safety system or pathway where that system is the supported parent boundary.
Reports
88
Distinct published reports
Individual concerns
92
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
151
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 Care27
NHS England16
Greater Manchester Mental Health NHS Foundation Trust6
Essex Partnership University NHS Foundation Trust5
National Institute for Health and Care Excellence4
Care Quality Commission3
Norfolk and Suffolk NHS Foundation Trust3
North East London NHS Foundation Trust3
University Hospitals Sussex NHS Foundation Trust3
Barking, Havering and Redbridge University Hospitals NHS Trust2
King'S College Hospital NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
North London NHS Foundation Trust2
North West Ambulance Service NHS Trust2
Nottinghamshire Healthcare NHS Foundation Trust2
NHS trust56
Ministerial department27
Executive non-departmental public body16
Healthcare site11
Integrated care board10
English metropolitan district council4
Independent healthcare provider4
Clinical commissioning group3
Domiciliary care provider3
English unitary authority3
Health and social care service regulator3
Local health board3
Health professional body2
London borough council2
Professional body2
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.
West Sussex, Brighton and Hove
Concerns raised1
Lack of a designated lead with oversight and authority over coordinated care
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.
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
Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
West Sussex, Brighton and Hove
Concerns raised1
Lack of a designated lead with full oversight and authority over coordinated care
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.
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.1
Action
Share the draft Personalised Care Framework with NHS organisations ahead of publication.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 2 April 2026.
Inner North London
Concerns raised1
Failure to provide coordinated care in A&E
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.1
Action
Introduce clinical operational standards for the first 72 hours of hospital care.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2025.
Inner South London
Concerns raised1
Failure to maintain continuity of care across admitting teams
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.
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.5
Action
Produce and use the Problem List Etiquette Guide to standardize problem-list and associated documentation practices.
Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Establish a cross-Trust EPIC Documentation Quality Group to assess data quality, oversee documentation enhancements and lead targeted quality-improvement initiatives.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2025.
Action
Agree EPIC documentation metrics and audit standards to establish baseline quality and track improvement.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Action
Oversee EPIC build changes, including navigators and note templates, to facilitate documentation quality improvement.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Action
Design and oversee targeted documentation quality-improvement projects before wider rollout.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Cumbria
Concerns raised1
Lack of clear responsibility for care of patients during illness
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.4
Action
Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2025.
Action
Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 15 July 2025.
Action
Continue discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
Stated by Cumbria Health LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2025.
Action
Introduce outcomes-based funding, integrated digital records and personalised care plans.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 15 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Wider risks from fragmented responsibility across NHS services should be addressed by national stakeholders through national guidance and structural changes.
Stated by Carlisle Central PracticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Contractual arrangements with partner organisations are considered sufficient to ensure continuity after NWAS transfers care.
Stated by North West Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Once a referral is accepted, responsibility for the patient's care rests with the receiving provider rather than NWAS.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised1
Failure to establish clear responsibility for patient care
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.
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.1
Action
Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.
Stated by Somerset NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to provide joined-up care between different agencies
This report raised 4 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing processes require enquiries about support networks and promptly sending mental health assessment summaries to service users’ GPs.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust cannot involve other relevant parties without the service user’s consent and relies on the service user identifying those parties.
Stated by North London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A private psychotherapist cannot currently be included in integrated care planning, limiting the ability to coordinate care across agencies.
Stated by British Association For Counselling And PsychotherapyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Failure to provide a care co-ordinator or key worker after hospital discharge
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.
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.1
Action
Progress the Quality Improvement project to make care-transfer changes sustainable, Trust-wide and effective in mitigating recurrence risk.
Stated by Oxford Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
Manchester South
Concerns raised1
Failure to maintain holistic oversight of patients receiving care from multiple practitioners
This report raised 4 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
Discuss adding record-keeping resources to the Hub Plus online information and support suite.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
Action
Discuss high-quality patient-record and medical-record guidance at a Clinical Governance Leads patient-safety agenda item.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
Manchester South
Concerns raised1
Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
This report raised 6 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.4
Action
Revise the repatriation procedure to support communication and continuity of care for international patients.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Action
Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 October 2024.
Action
Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Action
Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Stated by Trafford Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.
Stated by North West Ambulance Service NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures of the end-to-end patient-care continuity process, including unclear or unassigned responsibility, changing or excessive personnel, inadequate continuity between clinicians or services, and insufficient coordination that leaves care fragmented or without consistent oversight.
