Recurring concern
Failure to provide continuity of patient care
Pin
Get email alerts
Request correctionFirst reported 4 Sep 2013•Latest report 15 Jun 2026
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
- Individual concerns
- 92
- Date range
- 2013–2026
- Stated actions
- 151
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
-
Concerns raised1
Failure to establish whether specialist allergy care was being provided
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Require clinical staff to review AAI prescriptions, device understanding and relevant secondary-care support whenever attending patients use adrenaline.
Stated by the three G.Ps that were interested persons in the above matter -
Action
Check during medication reviews whether patients turning eighteen are appropriately transitioned to adult allergy specialists where necessary.
Stated by the three G.Ps that were interested persons in the above matter -
Action
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Stated by NHS England
-
Action
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Stated by NHS England
-
Concerns raised1
Failure of interagency communication to produce a clear and effective care plan for people with learning disabilities
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Publish an evidence review of care co-ordination for people with learning disabilities, focused on health and wellbeing.
Stated by Department of Health and Social Care -
Action
Improve timely discharge-summary publication, targeting delivery within 48 hours and performance above the Trust’s 95% standard.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
The local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Stated by Department of Health and Social Care
-
Position
Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.
Stated by NHS Greater Manchester Integrated Care Board
-
Concerns raised1
Failure to provide continuity of antenatal care for a high-risk pregnancy
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to assign a single properly informed clinician to coordinate complex post-operative care
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 concernsEach 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
Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The closed intensive care model clearly assigns responsibility for PICU care and identifies the PICU Consultant as the decision maker.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
-
Concerns raised2
Lack of a single clinician responsible for patient care
Fragmented responsibility for prison healthcare
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
Assign prisoners with chronic conditions to a named clinician.
Stated by NHS England -
Action
Commission prison healthcare through a Prime Provider model using a single contract, provider and database.
Stated by NHS England -
Action
Revise the tripartite prison healthcare partnership agreement to add the Department of Health and Social Care and Ministry of Justice for greater oversight and accountability.
Stated by Department of Health and Social Care
-
Action
Publish and operate the National Partnership Agreement for Prison Healthcare 2018–21 as a joined-up framework for collaborative prison healthcare delivery.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure to provide care coordination after placement with a private provider
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of continuity of care in antenatal appointments
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 concernsEach 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 two continuity-of-carer pathway teams providing named midwives and buddies throughout antenatal, birth and postnatal care.
Stated by Portsmouth Hospitals University NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Handheld notes, scheduled checks and trained midwives are considered sufficient to identify and escalate pregnancy abnormalities despite lack of continuity.
Stated by Portsmouth Hospitals University NHS Trust
-
Concerns raised1
Failure to provide assertive care coordination for patients at risk of disengagement and relapse
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to allocate a health professional to oversee and coordinate care for children with multiple specialist needs
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to provide continuity in the number of staff involved in care
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 concernsEach 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
Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Stated by Norfolk and Suffolk NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Stated by Norfolk and Suffolk NHS Foundation Trust
Data last updated 7 September 2026