Recurring concern
Failure to reassess treatment options when clinically indicated
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Request correctionFirst reported 30 Jul 2014•Latest report 25 Jun 2026
What this concern includes
Includes failures to review, reconsider, escalate or revise treatment options when treatment is significantly delayed, the patient's condition changes, or other clinically relevant circumstances indicate that the existing plan should be reassessed.
Not included
- Excludes generic delays in treatment where no failure to reassess or escalate treatment options is identified.
- Excludes failures limited to informed-consent discussions, documentation or communication where treatment options were otherwise appropriately reviewed.
- Excludes failures concerning diagnosis, referral or treatment delivery when no deficient reconsideration or escalation of treatment options is asserted.
- Excludes reassessment processes governed by a separately named clinical condition or treatment pathway when that named concern provides the more specific supported boundary.
- Reports
- 7
- Individual concerns
- 8
- Date range
- 2014–2026
- Stated actions
- 6
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
Delays in amending medication when presenting symptoms indicate a different treatment
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.
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
Mental health services retain responsibility for prescribing and antipsychotic dose changes when a patient is under specialist care.
Stated by The Foxhayes Surgery
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Concerns raised1
Failure to consider or plan alternative pain management during opioid overdose treatment
This report raised 18 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
Share opioid reversal guidance through palliative-care educational events and hold collaborative opioid-learning events with the integrated care system.
Stated by the Princess Alexandra Hospital NHS Trust
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 hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS England
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Concerns raised1
Lack of specific guidance for considering alternative methods of treatment for patients at high risk of acquiring Covid-19
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.
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Concerns raised1
Failure to risk-assess the appropriateness of PEG insertion
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.
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
Rewrite the Enteral Feeding Guideline to clarify absolute and relative PEG contraindications.
Stated by Queen Victoria Hospital NHS Foundation Trust -
Action
Use a PEG safety checklist with documented MDT decisions, contraindication checks, stop points and risk assessments.
Stated by Queen Victoria Hospital NHS Foundation Trust -
Action
Audit prospective PEG practice, including stickers, MDT documentation, consent and checklist use.
Stated by Queen Victoria Hospital NHS Foundation Trust
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Action
Request and review the trust’s completed prospective PEG audit to obtain assurances about safe care and treatment.
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.2
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Position
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Stated by Department of Health and Social Care
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Position
Pre-operative assessment considers suitability for surgery based on available facilities, while the laboratory agreement requires urgent specimens to be processed within one hour.
Stated by Care Quality Commission
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Concerns raised1
Failure to reassess diagnoses and escalate treatment despite continuing clinical decline
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
Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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Concerns raised2
Failure to reassess treatment options in response to significant treatment delays
Failure to conduct detailed assessment and re-consult treatment options during clinical deterioration
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.
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 escalate treatment options when clinically indicated
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026