Unreliable use of hospital passports to support safe care
First to latest report 30 Sep 2019 — 7 Jul 2025
Reports that mention this concern
5
Times this concern has been raised
5
Stated actions linked to this concern
11
What this concern includes
Includes failures of the hospital-passport process, including staff understanding, recognition, activation, reading, interpretation, communication and use of the passport to support safe care and patient involvement.
What is not included
Excludes generic communication, training, documentation or reasonable-adjustment deficiencies that are not specifically tied to the hospital-passport process.
Excludes deficiencies in discharge passports or other passport-like documents unless the assertion concerns the same hospital-passport system for communicating a patient's needs during care.
Excludes failures to involve families, carers or patients where no hospital-passport use or activation failure is identified.
Excludes clinical treatment, assessment or care failures that do not involve the reliability of hospital-passport use.
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.
Department of Health and Social Care2
Lancashire Teaching Hospitals NHS Foundation Trust1
NHS England1
NHS Greater Manchester Integrated Care Board1
Northern Care Alliance NHS Foundation Trust1
Oldham Borough Council1
Sheffield Teaching Hospitals NHS Foundation Trust1
NHS trust3
Ministerial department2
English metropolitan district council1
Executive non-departmental public body1
Integrated care board1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
Avon
Concerns raised1
Incomplete use of hospital passports for people with ME
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to utilise hospital passports
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Greater Manchester Integrated Care Board
Northern Care Alliance 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.9
Northern Care Alliance NHS Foundation Trust
Review the Learning Disability and Autism Policy to add guidance on specialist referrals and Hospital Passport use.
Northern Care Alliance NHS Foundation Trust
Complete the multidisciplinary review of the Enhanced Patient Observation policy to address learning disability needs and active Hospital Passport use.
Northern Care Alliance NHS Foundation Trust
Disseminate the Share Learning Take 5 education on learning disability care, diagnostic overshadowing, communication, Hospital Passports and carer involvement.
Northern Care Alliance NHS Foundation Trust
Implement Patient Care Alert procedures to verify contact details, contact care providers, obtain Hospital Passports, and record unresolved information for nursing follow-up.
Northern Care Alliance NHS Foundation Trust
Add a Hospital Passport prompt and learning disability indicator to the patient-status-at-a-glance board.
Northern Care Alliance NHS Foundation Trust
Red-flag patients with learning disabilities or Hospital Passports in daily safety huddles and assign senior nurse oversight of vulnerable patients.
Northern Care Alliance NHS Foundation Trust
Continue quarterly Senior Nurse Walkabout reviews of learning disability identification, safety-huddle flags, Hospital Passport availability and currency.
Northern Care Alliance NHS Foundation Trust
Use and further develop the Enhanced Patient Observation audit tool and targeted training to improve person-centred observation practice and quality assurance.
NHS Greater Manchester Integrated Care Board
Remind staff to check for and seek Hospital Passports at every presentation, regardless of whether records or systems identify one.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Northern Care Alliance NHS Foundation Trust
The initial absence of the Hospital Passport did not impact the patient’s care, although its immediate availability remains important.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Limited nursing-team understanding of when to instigate the hospital passport system
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Failure to understand and properly use hospital passports
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Teaching Hospitals 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.2
Sheffield Teaching Hospitals NHS Foundation Trust
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Sheffield Teaching Hospitals NHS Foundation Trust
Re-launch the Health Passport, All About Me booklet and Hospital Communication Booklets through a communication strategy promoting accessibility and use.
Manchester South
Concerns raised1
Failure to make the needs passport accessible to all staff caring for the patient
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.