Recurring concern
Failure to provide continuity of patient care
- Reports that mention this concern
- 88
- Times this concern has been raised
- 92
- Stated actions linked to this concern
- 151
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.
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.
Reports and published responses 88 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- NHS England
- the three G.Ps that were interested persons in the above matter
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
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the three G.Ps that were interested persons in the above matter
Require clinical staff to review AAI prescriptions, device understanding and relevant secondary-care support whenever attending patients use adrenaline.
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the three G.Ps that were interested persons in the above matter
Check during medication reviews whether patients turning eighteen are appropriately transitioned to adult allergy specialists where necessary.
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NHS England
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
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NHS England
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS England
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
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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.
Linked responses
- Department of Health and Social Care
- NHS Greater Manchester 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.2
-
Department of Health and Social Care
Publish an evidence review of care co-ordination for people with learning disabilities, focused on health and wellbeing.
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NHS Greater Manchester Integrated Care Board
Improve timely discharge-summary publication, targeting delivery within 48 hours and performance above the Trust’s 95% standard.
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 local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
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NHS Greater Manchester Integrated Care Board
Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- Great Ormond Street Hospital for Children 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.3
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Great Ormond Street Hospital for Children NHS Foundation Trust
Require high-risk patient flagging, PICU team briefings, admission reminders and daily admission-risk discussions for elective spinal admissions.
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Great Ormond Street Hospital for Children NHS Foundation Trust
Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
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Great Ormond Street Hospital for Children NHS Foundation Trust
Publish and use a spinal surgery pathway guideline defining responsibilities for complex cardiac patients admitted to PICU.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Great Ormond Street Hospital for Children NHS Foundation Trust
The closed intensive care model clearly assigns responsibility for PICU care and identifies the PICU Consultant as the decision maker.
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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.
Linked responses
- Department of Health and Social Care
- 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.4
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NHS England
Assign prisoners with chronic conditions to a named clinician.
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NHS England
Commission prison healthcare through a Prime Provider model using a single contract, provider and database.
-
Department of Health and Social Care
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.
-
Department of Health and Social Care
Publish and operate the National Partnership Agreement for Prison Healthcare 2018–21 as a joined-up framework for collaborative prison healthcare delivery.
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
Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- Portsmouth Hospitals University 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
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Portsmouth Hospitals University NHS Trust
Establish two continuity-of-carer pathway teams providing named midwives and buddies throughout antenatal, birth and postnatal care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Portsmouth Hospitals University NHS Trust
Handheld notes, scheduled checks and trained midwives are considered sufficient to identify and escalate pregnancy abnormalities despite lack of continuity.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- Norfolk and Suffolk 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.1
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Norfolk and Suffolk NHS Foundation Trust
Apply the national 39-point fidelity scale across the Trust to identify improvement areas and consistently match clinicians with patients using daily planning.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Norfolk and Suffolk NHS Foundation Trust
The CRHT cannot guarantee that service users will see a limited number of staff because intensive support requires flexible 24/7 staffing.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026