Recurring concern
Failure to reliably identify and respond to clinically significant weight change
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Request correctionFirst reported 17 Nov 2014•Latest report 23 Jun 2025
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.
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.
- Reports
- 8
- Individual concerns
- 9
- Date range
- 2014–2025
- Stated actions
- 14
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 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.
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.8
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Action
Review information-sharing, safeguarding policies, and related procedures.
Stated by Moorbridge Alternative Education Partnership School -
Action
Reinforce all staff understanding of safeguarding and timely information-sharing requirements through annual and ongoing training.
Stated by Moorbridge Alternative Education Partnership School -
Action
Continue monitoring and enhancing procedures to prevent future communication lapses.
Stated by Moorbridge Alternative Education Partnership School
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Action
Develop improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.
Stated by 49 Marine Avenue GP Surgery (NPC Surgery -
Action
Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
Stated by Department of Health and Social Care -
Action
Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
Stated by Department of Health and Social Care -
Action
Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Discuss and implement improved information sharing between primary and secondary healthcare pathways through the NENC GP/provider interface group.
Stated by Northumbria Healthcare NHS Foundation Trust
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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.
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
The Queen Elizabeth Hospital should respond to the concerns outside the second part of the first concern.
Stated by Norfolk and Suffolk NHS Foundation Trust
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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.
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
Develop and improve the Pandora information system through a staff user group.
Stated by Jeesal Residential Care Services Limited
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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.
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.5
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Action
Record nutrition assessments, care plans, MUST scores, BMI, weight loss, fluid intake and food intake in the Patient Bedside Safety Booklet.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Deliver annual MaST training on MUST scoring, nutrition screening and assessment, supported by online learning and ward-based refresher training.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Include MUST checks in daily ward huddles and escalate nutrition concerns to the nurse in charge.
Stated by Surrey and Sussex Healthcare NHS Trust
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Action
Conduct twice-weekly nutritional ward rounds led by a Consultant Gastroenterologist.
Stated by Surrey and Sussex Healthcare NHS Trust -
Action
Implement a formal complex nutrition MDT meeting with active surgeon membership.
Stated by Surrey and Sussex Healthcare NHS Trust
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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.
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 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.
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 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.
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
Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
Stated by Stoke-on-Trent City Council
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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.
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