Recurring concern
Inadequate safety-netting advice for patients and carers
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Request correctionFirst reported 6 May 2016•Latest report 10 Nov 2025
What this concern includes
Includes failures of safety-netting advice provided to patients, parents, carers or receiving care providers after assessment, treatment, discharge or reported deterioration, including advice that is absent, delayed, undocumented, unclear or not tailored to a material suspected condition.
Not included
- Excludes failures of clinical assessment, monitoring, diagnosis or treatment where no safety-netting advice deficiency is identified.
- Excludes generic communication or documentation failures that are not specifically part of safety-netting.
- Excludes staffing, workload or workforce wellbeing concerns unless the report directly identifies their effect on safety-netting provision.
- Excludes emergency call-system or escalation-process deficiencies that do not concern advice given to patients, carers or receiving care providers.
- Reports
- 29
- Individual concerns
- 30
- Date range
- 2016–2025
- Stated actions
- 24
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to ensure safety-netting when a Care Coordinator is absent
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 concernsEach 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
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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 Trust -
Action
Provide direct clinician contact and prioritised MDT support, including safe-hours overtime, for patients awaiting an allocated care coordinator.
Stated by Essex Partnership University NHS Foundation Trust
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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Position
Existing caseload oversight, risk prioritisation and clinician contact arrangements satisfactorily address gaps when patients lack an allocated care coordinator.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to clearly communicate sensitising events and the required Anti-D action
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 concernsEach 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
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Action
Highlight the importance of giving RhD-positive mothers appropriate guidance, written information and advice on when to contact services.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Failure to provide advice on when to seek further medical assistance
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 concernsEach 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
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Action
Provide a full-time heart-centre discharge coordinator using a multidisciplinary approach for discharge planning.
Stated by Oxford University Hospitals NHS Foundation Trust
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Concerns raised1
Absence of safety-netting advice for patients leaving the hospital
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 concernsEach 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
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Action
Launch a patient-designed discharge safety-netting leaflet after final approval and printing.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Launch and weekly-audit a two-month Emergency Department discharge helpline pilot.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Failure to provide information about symptoms indicating deterioration
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 concernsEach 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
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Position
A discharge sheet provided safety-netting information, so it was not correct that no relevant information or consultation outcome was left.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Concerns raised1
Failure to directly inform higher-risk patients when internal referrals are declined, including providing interim safety-netting advice
Responses linked to these concernsEach 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
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Action
Provide therapists with guidance on advising newly referred higher-risk clients, including the timing limitations of consultant psychiatrist assessments.
Stated by Priory Group -
Action
Require CCT staff and therapists to document interventions and communicate promptly with each other and newly referred clients.
Stated by Priory Group -
Action
Carry out periodic CCT audits of client contacts to check that documentation and communication requirements are achieved.
Stated by Priory Group
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Concerns raised1
Inadequate pre- and post-procedure written documentation of advice to seek further medical attention after vomiting
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 concernsEach 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
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Action
Strengthen post-ERCP discharge information to emphasise returning to hospital if vomiting or other symptoms develop at home, subject to governance ratification.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised1
Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
This report raised 23 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 record interim deterioration advice and action information
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 concernsEach statement is shown once, even when linked to more than one 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 clear discharge advice to parents about a healthy urine stream in babies
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026