Recurring concern
Unreliable staff access to and understanding of safety-critical guidance
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Request correctionFirst reported 3 Dec 2013•Latest report 11 Jan 2023
What this concern includes
Includes failures of staff-facing arrangements to provide access to safety-critical guidance or learning material and to verify that relevant staff have accessed, considered and understood it, including computer-based material and associated acknowledgement or comprehension checks.
Not included
- Excludes substantive deficiencies in the guidance itself where access or staff understanding is not the reported unsafe condition.
- Excludes generic staff training, staffing or communication deficiencies that are not specifically tied to access to or understanding of safety-critical guidance.
- Excludes failures to implement a safety change after staff have reliably accessed and understood the relevant guidance.
- Excludes named systems, pathways or hazard-specific guidance where that narrower concern provides the more specific supported boundary.
- Reports
- 13
- Individual concerns
- 13
- Date range
- 2013–2023
- Stated actions
- 10
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
Lack of checks that staff have considered and understood safety material
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
Unavailability of the policy to all healthcare staff in the surgery
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.1
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Action
Create an electronic-record alert for drugs in the specified prescribing group, warning prescribers about dosage and alcohol-related risks.
Stated by Swanage Medical Practice
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Concerns raised1
Insufficient dissemination, awareness and continuous training on the Vascular Pathway
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 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 ensure staff awareness of the Standard Operating Procedure for Enhanced Care/Observation
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 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
Develop E-learning packages for SafeCare and EICO and make them accessible to relevant staff through the Electronic Staff Record system.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Add required SafeCare and EICO competencies to staff learning profiles and compliance matrices within the Electronic Staff Record system.
Stated by South Tyneside and Sunderland NHS Foundation Trust
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Concerns raised1
Lack of staff knowledge of applicable clinical guidelines and policies
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.
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 Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of guidance for frontline staff on promptly capturing evidence after falls
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.
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
Run the Safer Mobility Collaborative, including immediate post-fall assessment, staff statements and patient discussions to confirm safety actions.
Stated by Stockport NHS Foundation Trust -
Action
Use thrice-weekly Quality Safety Leadership Summits to monitor falls, confirm investigations have started and verify inclusion of immediate statements.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Lack of clear guidance and staff understanding of medical conditions relevant to exercise
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 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 make the falls protocol clearly available to staff
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.1
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Action
Disseminate the falls protocol to staff and incorporate it into new-staff induction.
Stated by Care First Class (UK) Limited
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Concerns raised1
Failure of managers and staff to access computer-based health and safety material
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.1
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Action
Roll out refresher training and awareness raising so employees know where to find health and safety documents.
Stated by Agd Equipment Limited
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
Health and safety documents were available electronically and in hard copy, contrary to any premise that the company lacked accessible documentation.
Stated by Agd Equipment Limited
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Concerns raised1
Insufficient visibility of the heparin administration poster’s direction to seek haematology advice for underweight patients
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026