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.
Brighton and Hove
Concerns raised1
Lack of continuity and active care
This report raised 17 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.
Nottinghamshire
Concerns raised2
Unclear responsibility for ensuring parental competence in NGT feeding
Lack of clear allocation of a named keyworker or lead nurse for community care coordination
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.
Cheshire
Concerns raised1
Inadequacies in mental health care planning and communication
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.2
Action
Maintain nationally specified integrated stepped mental-health care, including consultant psychiatry, long-term care planning and continuity of care.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 June 2016.
Action
Roll out the revised Person Escort Record and provide training so operational staff transfer relevant health information throughout custody transitions.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 June 2016.
South Wales Central
Concerns raised1
Lack of continuity of treatment
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.7
Action
Amend and implement the Unable to Make Contact Protocol for CRHT staff responding to missed contacts and unavailable service users.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Action
Pilot and audit the amended Unable to Make Contact Protocol, collating outcomes for reporting to Patient Safety.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 May 2016.
Action
Implement the Acute Service Line Welfare Check Protocol for inpatients and CRHT service users.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Action
Highlight the Unable to Make Contact Protocol during shift handovers, team meetings and individual supervision where necessary.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Action
Launch, train staff on and cascade the new Unable to Make Contact Protocol across CRHT teams, matrons and managers.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Action
Maintain a fully functioning Crisis Resolution Home Treatment Team providing acute hospital-level care at home.
Stated by Powys Teaching Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Action
Allocate additional funding for Montgomeryshire services, including additional care coordination to address out-of-county admissions.
Stated by Powys Teaching Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 11 May 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A hospital admission does not require changing the patient's statutory care coordinator under the applicable mental health care arrangements.
Stated by Powys Teaching Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing statutory care coordinators and holistic care and treatment plans are considered sufficient to assure continuity for Welsh patients placed out of area.
Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Lack of accountable coordination and continuity of patient care
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.
Black Country
Concerns raised1
Lack of continuity and overall ownership of treatment in general practice
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
Lack of clarity about the designated contact between patients and the Intake team
This report raised 16 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
Review and implement AABIT standard operating procedures.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 November 2015.
Essex
Concerns raised1
Failure to carry out the named nurse role
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.
Gateshead and South Tyneside
Concerns raised1
Failure to assign overall clinical management 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Failure of healthcare and discipline staff to provide an integrated response to drug-related presentations
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.2
Action
Develop and consult on the Drugs and Alcohol Recovery Teams pathway and brief key leaders before wider circulation.
Stated by Eric StephensStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2015.
Action
Introduce monthly multidisciplinary substance misuse training for healthcare, discipline and other prison staff.
Stated by Eric StephensStated completedThe respondent said that this action was complete when they made their response on 28 October 2015.
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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.
