First reported 10 Oct 2013•Latest report 14 Jan 2026
Definition
What this concern includes
Includes failures in clinical assessment processes where face-to-face assessment is clinically indicated but is omitted, not offered, not required by policy, or replaced by remote contact without an adequate safety threshold; include the anchor and comparable primary-care or community-care assertions.
Not included
Excludes failures limited to telephone mental health assessment, which belong to the separately named mental-health telephone-assessment concern when that is the supported boundary.
Excludes remote consultations where the report does not identify a clinically indicated need for face-to-face assessment.
Excludes failures in treatment, referral, follow-up or diagnostic testing after an adequate face-to-face assessment has occurred.
Excludes generic access, staffing or communication deficiencies unless they directly result in failure to provide clinically indicated face-to-face assessment.
Reports
21
Distinct published reports
Individual concerns
21
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
24
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.
Department of Health and Social Care7
NHS England2
NHS Greater Manchester Integrated Care Board2
49 Marine Avenue Surgery1
Ayurvedic Professionals Association1
Belmont Health Centre1
Berkshire Healthcare NHS Foundation Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
East London NHS Foundation Trust1
General Medical Council1
General Pharmaceutical Council1
Greater Manchester Health and Social Care Partnership1
Herefordshire and Worcestershire Health and Care NHS Trust1
Kent and Medway Mental Health NHS Trust1
NHS trust9
Ministerial department7
Healthcare site5
Integrated care board3
Executive non-departmental public body2
Company limited by guarantee1
English unitary authority1
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Health-system partnership1
Independent healthcare provider1
Medicines and medical devices regulator1
Multi-service care provider1
Professional body1
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.
Kent and Medway
Concerns raised1
Failure to act on family-provided information indicating heightened and escalating risk
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 concerns
Each 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.4
Action
Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.
Stated by Kent and Medway Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
Action
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Stated by Kent and Medway Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Update the Duty Standard Operating Procedure to require same-day routine referral action and careful consideration of family members’ information.
Stated by Vita Health Group LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Action
Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.
Stated by Vita Health Group LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.
Stated by Vita Health Group LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hampshire, Portsmouth Southampton
Concerns raised1
Failure of Urgent Care Centres to provide doctor examination
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North London
Concerns raised1
Failure to provide face-to-face consultations by a doctor
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 concerns
Each 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
Position
NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Liverpool and the Wirral
Concerns raised1
Failure to ensure face-to-face clinical assessment of vulnerable elderly patients
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Northumberland
Concerns raised1
Lack of in-person dietetic assessment recording weight and clinical observations
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 concerns
Each 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
Action
Reinforce face-to-face contact requirements for patients with weight loss or malnutrition through team reminders and monthly meetings.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.
Stated by Northumbria Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A return to face-to-face appointments as standard requires additional resources and a commissioning review, preventing immediate universal implementation.
Stated by Northumbria Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The service cannot guarantee that every first appointment will be face-to-face because patient choice may prevent this.
Stated by Northumbria Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Reliance on telephone rather than face-to-face appointments
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 concerns
Each 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
Action
Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
Action
Implement quarterly audits of documented rationales for remote outpatient appointments and share results at divisional safety and quality meetings.
Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
Norfolk
Concerns raised1
Failure to ensure preoperative review by a surgeon
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face
Responses linked to these concerns
Each 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
Action
Conduct face-to-face assessments following adult social care referrals for care and support.
Stated by Milton Keynes City CouncilStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Manchester South
Concerns raised1
Failure to provide face-to-face clinical review
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Prescribing antibiotics without examining the patient
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Pin
Get email alerts
Request correction
Includes failures in clinical assessment processes where face-to-face assessment is clinically indicated but is omitted, not offered, not required by policy, or replaced by remote contact without an adequate safety threshold; include the anchor and comparable primary-care or community-care assertions.
