Recurring concern
Failure to provide timely clinical care
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Request correctionFirst reported 28 Aug 2013•Latest report 14 Jan 2026
What this concern includes
Includes delays or omissions in providing clinically required patient care, medical review or treatment where the delay can permit deterioration, worsen risk or reduce available treatment options, including the anchor's similar delays in patient care and delayed necessary treatment after recognition of a life-threatening condition.
Not included
- Excludes delays confined to a separately named clinical pathway, condition, service or operational process where that named concern provides the more specific supported boundary.
- Excludes delays in ambulance attendance, hospital admission, specialist referral, diagnostic investigations or discharge when those processes are the specific unsafe condition rather than delayed clinical care generally.
- Excludes failures to recognise deterioration where no delay in providing clinical care is identified.
- Excludes delays caused solely by patient choice or clinically justified prioritisation where care remained within a safe timeframe.
- Reports
- 17
- Individual concerns
- 17
- Date range
- 2013–2026
- Stated actions
- 22
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 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 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.4
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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 Trust -
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 Trust -
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 Ltd
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Action
Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.
Stated by Vita Health Group Ltd
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
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 Ltd
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Concerns raised1
Delays in providing necessary treatment after recognition of a life-threatening condition
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.3
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Action
Continue piloting Martha’s Rule, meeting other pilot sites and sharing implementation learning and data with NHS England.
Stated by Homerton Healthcare NHS Foundation Trust -
Action
Deliver simulation training to clinical staff on closed-loop communication and direct instruction during emergency management of sepsis and shock.
Stated by Homerton Healthcare NHS Foundation Trust -
Action
Develop and deliver closed-loop communication training for resident doctors through the Regional Trainee Teaching programme.
Stated by Homerton Healthcare NHS Foundation Trust
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Concerns raised1
Delays in further clinical review after continued sepsis triggers
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 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
Delays in inserting required NG tubes
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.
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
Review the existing nutrition policy and agree nutritional-support and nasogastric-tube insertion requirements for detained patients, including restraint situations.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation Trust -
Action
Put in place a standard operating procedure with timescales for timely nutritional support and clear cross-Trust responsibilities.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation Trust
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Concerns raised1
Absence of directions specifying action timetables for life-threatening conditions
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.
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 arrange medical assessment after disclosed excess oramorph ingestion
This report raised 1 other concern. 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.4
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Action
Review and revise medication policies, procedures and working practices to prevent recurrence of medication-related incidents.
Stated by Cherish Homecare Limited -
Action
Implement a medication-overdose procedure requiring staff to seek medical assistance regardless of service-user or next-of-kin agreement.
Stated by Cherish Homecare Limited -
Action
Disseminate the medical-assistance procedure to office staff through meetings and to care staff through refresher training and direct notifications.
Stated by Cherish Homecare Limited
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Action
Introduce the medication-overdose policy and medical-assistance procedures to new staff through induction.
Stated by Cherish Homecare Limited
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Concerns raised1
Failure to ensure timely medical review after deterioration and repeated requests
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.
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 provide medical review after ward rounds
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 provide timely clinical review following reported deterioration
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.2
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Action
Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.
Stated by Care Quality Commission -
Action
Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.
Stated by Care Quality Commission
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
Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.
Stated by Care Quality Commission
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Concerns raised1
Failure to provide clinical or nursing review after deterioration in consciousness
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.
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
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
Data last updated 7 September 2026