First reported 5 Sep 2013•Latest report 16 Jun 2026
Definition
What this concern includes
Includes failures to recognise the need for and promptly seek medical, paramedic or other appropriate clinical assistance when a person's injury, pain, fall, deterioration or other condition warrants it, including failures in care homes and emergency-response settings.
Not included
Excludes delays or failures occurring after medical assistance has already been requested, including ambulance attendance or hospital handover delays.
Excludes failures limited to the quality of assessment or treatment after medical assistance has been obtained.
Excludes failures to seek advice about routine care arrangements where no immediate or clinically warranted need for medical attention is identified.
Excludes generic staffing, training, communication or documentation deficiencies unless they directly result in failure to seek warranted medical attention.
Reports
56
Distinct published reports
Individual concerns
61
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
81
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.
Care Quality Commission9
NHS England4
Department of Health and Social Care3
Recipient name withheld3
National Institute for Health and Care Excellence2
University Hospitals Sussex NHS Foundation Trust2
Abbey Care Village1
Adbolton Hall1
Angel Solutions (UK) Ltd1
Appello Careline Limited1
Association of Ambulance Chief Executives1
Barts Health NHS Trust1
Belle Green Court1
Bury Borough Council1
Care First Class (UK) Limited1
NHS trust20
Health and social care service regulator9
Private limited company7
Residential care home7
Executive non-departmental public body5
Healthcare site5
Type not available5
English metropolitan district council4
Ministerial department4
Domiciliary care provider3
Nursing home3
Care-home operator2
Health professional body2
Police force2
Company limited by guarantee1
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.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to seek urgent clinical assistance for significant per rectum bleeding
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.4
Action
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Action
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 May 2024.
Gloucestershire
Concerns raised1
Uncertainty about when medical professionals should call the ambulance service
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
Review the medical-emergency escalation process and reinforce it through resuscitation training.
Stated by Gloucestershire Health and Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing medical-emergency escalation process remains fit for purpose and is reinforced through training and induction.
Stated by Gloucestershire Health and Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Teesside and Hartlepool
Concerns raised1
Failure to respond to reported pain with pain relief or medical escalation
This report raised 11 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
Mandate pain assessments at every set of physiological observations through the electronic observation system.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Action
Incorporate objective pain assessment tools and visual alerts for patients reporting moderate-to-severe pain.
Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2024.
Action
Monitor compliance with timely pain assessments and reassessments on an ongoing basis.
Stated by South Tees Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 January 2024.
Action
Implement the Call 4 Concern initiative, enabling patients and families to request Critical Care Outreach review.
Stated by South Tees Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Inner North London
Concerns raised1
Failure to escalate unsuccessful nasogastric tube placement to appropriate medical expertise
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.1
Action
Update the nasogastric-tube policy to cover surgical drainage and escalation of difficult or unsuccessful tube placement.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
UCLH states the NG tube was removed appropriately because drainage was low, and that subsequent insertion was inherently difficult and unpredictable.
Stated by University College London Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sefton, St Helens and Knowsley
Concerns raised2
Failure to summon emergency medical assistance when required
Failure to escalate concerning patient presentations to a doctor
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.
South Yorkshire (Western)
Concerns raised1
Failure to recognise when medical attention is required
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.1
Action
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
Stated by Sequoia CH Group LtdStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Derby and Derbyshire
Concerns raised1
Failure to respond appropriately to suspected infection when NEWS scores are low
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.
Surrey
Concerns raised1
Failure to follow escalation guidance for complex febrile seizures
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.
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
Review the JRCALC guidance on convulsions in children.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 31 March 2023.
Action
Continue reviewing the convulsions guidance through regular clinical-guideline review activity.
Stated by Association of Ambulance Chief ExecutivesStated plannedThe respondent said that this action was planned when they made their response on 31 March 2023.
Action
Inform ambulance-service medical directors and lead paramedics about the death and ask them to review relevant JRCALC guidance and local pathways.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 31 March 2023.
Action
Remind ambulance trusts about best-practice guidance on conveying children in face-to-face operational ambulance care.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 31 March 2023.
Action
Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The convulsions-in-children guideline does not need improvement at present, subject to routine review and updating when new clinical evidence emerges.
Stated by Association of Ambulance Chief ExecutivesNo action considered necessaryThe respondent said that no further action was needed.
Position
AACE is the appropriate organisation to decide whether JRCALC guidelines for paramedic seizure management require updates.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Stated by Royal College of Emergency MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Worcestershire
Concerns raised1
Delays in calling an ambulance when a resident’s condition requires emergency assistance
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.
Sefton St Helens & Knowsley
Concerns raised1
Failure to escalate patients’ deterioration and pain
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 to recognise the need for and promptly seek medical, paramedic or other appropriate clinical assistance when a person's injury, pain, fall, deterioration or other condition warrants it, including failures in care homes and emergency-response settings.
