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.
What is 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.
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.
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
Reports and published responses 88 reports
See individual reports that have raised this concern, and the actions taken in response
Worcestershire
Concerns raised1
Failure to ensure overall consultant responsibility for patients receiving care from multiple teams
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Worcestershire Acute Hospitals 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
Worcestershire Acute Hospitals NHS Trust
Share, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Norfolk
Concerns raised1
Failure to maintain continuity of inpatient care during ward moves
This report raised 1 other concern. 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.
Outer South London
Concerns raised1
Delays in organizations agreeing their roles
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
Ministry of Housing, Communities and Local Government
NHS England
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
Department of Health and Social Care
Continue joint work to improve integrated and coordinated care for people with co-occurring mental health and alcohol or drug use conditions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
Further information on Emily’s care coordination should be obtained from South East London Integrated Care Board.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Ministry of Housing, Communities and Local Government
The report has no specific policy implications for this department, so it will not provide a response.
Outside remitThe respondent said that this matter was outside its role or authority.
Ministry of Housing, Communities and Local Government
The Department for Health and Social Care is the lead department responsible for responding to the report.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Lack of continuity in primary care after patient relocation
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cornwall Council
Department of Health and Social Care
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
Cornwall Council
Provide Adult Social Care access to NHS SPINE to verify individuals’ GP registration records through its recording system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Primary care professionals remain responsible for attending relevant safeguarding meetings and transferring patient records between practices promptly.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Unclear responsibility for continuity of care
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Tameside and Glossop Integrated Care NHS Foundation Trust
Existing consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Confusion between doctors about responsibility for patients with dual orthopaedic and medical needs
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Barts 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.3
Barts Health NHS Trust
Display on-call doctors’ contact information in relevant clinical areas.
Barts Health NHS Trust
Update the orthopaedic–orthogeriatric interface and define junior doctors’ roles and responsibilities for patient assessment.
Barts Health NHS Trust
Escalate orthopaedic patients with clinical concerns to the on-call medical, Critical Care Outreach or intensive care teams for support and further management.
Essex
Concerns raised1
Failure to provide continuity and handover between hospital and community psychology services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University 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
Essex Partnership University NHS Foundation Trust
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Essex Partnership University NHS Foundation Trust
Regularly audit handovers to verify safe transfer of psychological care to community teams.
Essex Partnership University NHS Foundation Trust
Review the operational model for transitions and handovers between inpatient and community psychological services.
Essex Partnership University NHS Foundation Trust
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Essex Partnership University NHS Foundation Trust
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Essex Partnership University NHS Foundation Trust
Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex Partnership University NHS Foundation Trust
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Fragmentation of treatment across two sites
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.
East Riding and Hull
Concerns raised1
Lack of consistency and continuity among care staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
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
Department of Health and Social Care
Invest in recruiting and retaining additional mental health workers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
The Trust’s action plan and CQC monitoring are the established arrangements for addressing the identified safety concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Hampshire, Portsmouth and Southampton
Concerns raised1
Fragmented connectivity between mental health and physical or neurodivergence services
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
NHS Hampshire and Isle of Wight Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Establish a single community and mental health provider through Project Fusion.
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
NHS Hampshire and Isle of Wight Integrated Care Board
Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
NHS Hampshire and Isle of Wight Integrated Care Board
Operate an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
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.