Recurring concern
Failure to reliably identify and respond to clinically significant weight change
- Reports that mention this concern
- 8
- Times this concern has been raised
- 9
- Stated actions linked to this concern
- 14
What this concern includes
Includes failures to identify, review, discuss, monitor or respond to clinically significant weight gain or loss, including failure to use current weight information in multidisciplinary or other care reviews, set appropriate weight-related goals, refer for relevant support or initiate a clinical response.
What is not included
- Excludes general nutrition and hydration deficiencies where no clinically significant weight change is the material unsafe condition.
- Excludes routine weight recording failures where the weight information is otherwise reviewed and acted upon appropriately.
- Excludes failures concerning unrelated clinical measurements or body-composition concerns without a material patient-safety issue involving significant weight gain or loss.
- Excludes generic multidisciplinary meeting, care-planning or documentation deficiencies where weight change is not the safety-relevant object.
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 8 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Failure to share clinically significant eating and weight information with an appropriate body
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- 49 Marine Avenue GP Surgery (NPC Surgery
- Department of Health and Social Care
- Moorbridge Alternative Education Partnership School
- Northumbria Healthcare 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.8
-
Moorbridge Alternative Education Partnership School
Review information-sharing, safeguarding policies, and related procedures.
-
Moorbridge Alternative Education Partnership School
Reinforce all staff understanding of safeguarding and timely information-sharing requirements through annual and ongoing training.
-
Moorbridge Alternative Education Partnership School
Continue monitoring and enhancing procedures to prevent future communication lapses.
-
49 Marine Avenue GP Surgery (NPC Surgery
Develop improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.
-
Department of Health and Social Care
Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
-
Department of Health and Social Care
Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
-
Northumbria Healthcare NHS Foundation Trust
Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
-
Northumbria Healthcare NHS Foundation Trust
Discuss and implement improved information sharing between primary and secondary healthcare pathways through the NENC GP/provider interface group.
-
Concerns raised1
Failure to act on recorded weight loss
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Norfolk and Suffolk NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Norfolk and Suffolk NHS Foundation Trust
The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
-
Concerns raised1
Failure to address weight gain and set weight-loss goals in multidisciplinary reviews
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Jeesal Residential Care Services Limited
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
-
Jeesal Residential Care Services Limited
Develop and improve the Pandora information system through a staff user group.
-
Concerns raised1
Delay in recognising significant patient weight loss
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Surrey and Sussex Healthcare 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.5
-
Surrey and Sussex Healthcare NHS Trust
Record nutrition assessments, care plans, MUST scores, BMI, weight loss, fluid intake and food intake in the Patient Bedside Safety Booklet.
-
Surrey and Sussex Healthcare NHS Trust
Deliver annual MaST training on MUST scoring, nutrition screening and assessment, supported by online learning and ward-based refresher training.
-
Surrey and Sussex Healthcare NHS Trust
Include MUST checks in daily ward huddles and escalate nutrition concerns to the nurse in charge.
-
Surrey and Sussex Healthcare NHS Trust
Conduct twice-weekly nutritional ward rounds led by a Consultant Gastroenterologist.
-
Surrey and Sussex Healthcare NHS Trust
Implement a formal complex nutrition MDT meeting with active surgeon membership.
-
Concerns raised1
Failure to respond to substantial weight loss
This report raised 25 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.
-
Concerns raised1
Failure to monitor nutritional status and refer for dietary support
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.
-
Concerns raised1
Failure to refer for dietetic assessment after considerable weight loss
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Stoke-on-Trent City Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Stoke-on-Trent City Council
Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
-
Concerns raised2
Failure to implement nutrition charts for residents with significant weight loss
Delays in seeking medical advice after significant resident weight loss
This report raised 14 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026