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.
Inner North London
Concerns raised1
Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care
This report raised 2 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
Develop a bespoke organisational-development package to improve collaboration, communication and conflict management between hepatology and paediatric intensive care.
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 3 March 2022.
Essex
Concerns raised1
Lack of clarity about responsibility for oversight of patient care following discharge
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
This report raised 15 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
Develop a community eating disorder medical-monitoring pathway and accept medically stable patients based on clinical assessment rather than BMI alone.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Develop a shared operating procedure and training for communication between acute, community and specialist inpatient services.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Approve and implement an expanded adult community eating disorder service with psychiatric, physical-health, psychological and dietetic capacity.
Stated by NHS Bury Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Action
Implement the expanded adult eating disorder service to provide medical monitoring, specialist treatment, consultation and coordinated pathways.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Priory Hospital Cheadle Royal is not commissioned to provide community interventions, apart from assessments that may lead to admission.
Stated by Priory GroupOutside remitThe respondent said that this matter was outside its role or authority.
West Yorkshire Eastern
Concerns raised1
Lack of continuity in treatment
This report raised 13 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
Review the induction package to formalise explicit, proportionate support and supervision for locum medics.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Action
Review the clinical handover process for locum medics to support robust clinical decision-making.
Stated by Leeds and York Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 November 2021.
Leicester City and South Leicestershire
Concerns raised1
Lack of continuity in community nursing staff assessing wounds
This report raised 2 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.
East London
Concerns raised1
Failure to provide continuity of care coordination
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.4
Action
Deploy semi-permanent agency staff to support community recovery teams during recruitment.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 October 2021.
Action
Recruit additional staff above establishment to reduce care-coordinator caseloads and support relationship building.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 October 2021.
Action
Provide induction training and clinical supervision for permanent and temporary staff managing risks and patient relationships.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2021.
Action
Provide clinical supervisors with a care-coordination prompt covering relationship building, risk management and caseload management.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 October 2021.
Manchester City
Concerns raised1
Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment
This report raised 11 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
Audit CMHT care plans and CPA reviews to verify GP contact and contribution to reviews, sharing findings and any action plan with divisional leadership.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 October 2021.
Surrey
Concerns raised1
Lack of clarity about relative responsibility for patients’ overall medical management between Mayday Assistance Limited and air ambulance providers
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
Establish Air Ambulance Support Agreements with providers to clarify responsibilities and promote close working relationships on all cases.
Stated by Mayday Group LtdStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
Brighton and Hove
Concerns raised2
Lack of clear allocation of overall responsibility for care
Lack of a clear inter-organisational working policy
This report raised 2 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
Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2020.
Action
Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2020.
Action
Finalise a Brighton and Hove flowchart and local protocol clarifying how AMHPs secure care or treatment while patients await admission.
Stated by Brighton and Hove City CouncilStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing urgent demand meetings, Haven availability and agreed AMHP operational arrangements are considered sufficient to prevent the identified confusion recurring meanwhile.
Stated by Brighton and Hove City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Unclear responsibility for care decisions and placement suitability assessment
Lack of coordination and ownership of care in acute settings
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.15
Action
Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.
Stated by Bolton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Strengthen and ratify the Mental Capacity Act policy to clarify assessment responsibilities, decision makers and Independent Mental Capacity Advocate referrals.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Develop a Home First competency framework for recommending appropriate intermediate-care placements.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Bring the Home First Team, inpatient therapy services and Integrated Discharge Team under a single management structure to improve communication.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Bolton Council will provide a further detailed response on aspects of care coordination, ownership and decision-making.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton Council and GMMHFT will provide the full response to concerns about community care coordination and agency roles.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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.
