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.
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.
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, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2024.
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.
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.
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.
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 joint work to improve integrated and coordinated care for people with co-occurring mental health and alcohol or drug use conditions.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 9 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Further information on Emily’s care coordination should be obtained from South East London Integrated Care Board.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The report has no specific policy implications for this department, so it will not provide a response.
Stated by Ministry of Housing, Communities and Local GovernmentOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Department for Health and Social Care is the lead department responsible for responding to the report.
Stated by Ministry of Housing, Communities and Local GovernmentRedirects 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.
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
Provide Adult Social Care access to NHS SPINE to verify individuals’ GP registration records through its recording system.
Stated by Cornwall CouncilStated completedThe respondent said that this action was complete when they made their response on 20 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Primary care professionals remain responsible for attending relevant safeguarding meetings and transferring patient records between practices promptly.
Stated by Department of Health and Social CareRedirects 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.
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.2
Position
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting 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.
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
Display on-call doctors’ contact information in relevant clinical areas.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Action
Update the orthopaedic–orthogeriatric interface and define junior doctors’ roles and responsibilities for patient assessment.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
Action
Escalate orthopaedic patients with clinical concerns to the on-call medical, Critical Care Outreach or intensive care teams for support and further management.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 December 2023.
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.
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
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Regularly audit handovers to verify safe transfer of psychological care to community teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Review the operational model for transitions and handovers between inpatient and community psychological services.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Stated by Essex Partnership University NHS Foundation TrustDisputes 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.
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 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.
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
Invest in recruiting and retaining additional mental health workers.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 6 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust’s action plan and CQC monitoring are the established arrangements for addressing the identified safety concerns.
Stated by Department of Health and Social CareExisting 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.
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
Establish a single community and mental health provider through Project Fusion.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Develop a countywide neurodiversity best-practice network and working groups to create measurable, sustainable operating procedures.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Recommission autism and ADHD assessment and prescribing pathways to provide a cohesive population-wide service.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Operate an all-age autism and ADHD improvement group to oversee transformation of the neurodiversity pathway.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
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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.
