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.
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.
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
Implement and use a Trust-wide electronic Care Coordinator to Care Coordinator Transfer of Care Document for structured handovers and continuity oversight.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Norfolk
Concerns raised1
Lack of continuity of care across successive consultants
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.2
Action
Reduce locum consultant cover and develop a more substantive workforce to improve patient ownership.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Improve handover of care and communication between consultants.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Staffing shortages and working-time requirements prevent assigning the same consultant throughout an admission.
Stated by The TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Swansea and Neath Port Talbot
Concerns raised1
Lack of care-coordinator oversight for complex cases outside secondary mental health services
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.
Surrey
Concerns raised1
Lack of coordinated response across clinicians to febrile seizure presentations
This report raised 9 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.
Cornwall and Isles of Scilly
Concerns raised1
Lack of continuity in medical or nursing care for patients staying on AMU longer than usual
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.1
Position
A single named consultant for AMU patients staying over 48 hours is not adopted because existing speciality visiting consultant arrangements provide speciality care.
Stated by Royal Cornwall HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to establish daily skin-integrity monitoring responsibility
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.14
Action
Establish a dedicated telephone number and contact time for discussing hospital discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Share discharge communications and care plans with all providers involved in patients’ care.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Ensure robust and timely communication with all agencies involved in care arrangements.
Stated by Kapital Care (UK) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care arrangements.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sunderland
Concerns raised1
Insufficient recruitment and retention of midwives for continuity of 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.4
Action
Invest £165 million to grow and support the maternity workforce and improve neonatal care.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Action
Expand midwifery training places by 3,650 over four years.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 7 October 2022.
Action
Provide non-repayable annual training grants and additional financial support for eligible students and recruitment-shortage specialisms.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Action
Implement the NHS People Plan’s staff-retention measures, including wellbeing guardians, healthier working environments, flexible working and psychological support.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 October 2022.
Gwent
Concerns raised1
Failure to establish clear ownership of care between mental health and ENT 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.2
Action
Expand Adferiad through recurrent funding, broader eligibility and a multidisciplinary team providing assessment, care planning and rehabilitation expertise.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
Action
Map existing services to support appropriate pathway allocation for people referred to the expanded Adferiad service.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
East London
Concerns raised1
Failure to provide continuity of care
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.4
Action
Recruit temporary staff to maintain continuity while permanent care-coordinator vacancies are filled.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Prioritise mental-health vacancies and use off-framework agencies to retain locum support and consistency during short-term vacancies.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Use non-recurrent funding to recruit additional staff for increased referral volume and patient acuity.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Recruit eight additional band 6 community psychiatric nurses to meet increased workload.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Sunderland
Concerns raised1
Failure to maintain continuity of care for vascular referrals
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
