Recurring concern
Unreliable escalation by care staff for required medical attention
- Reports that mention this concern
- 48
- Times this concern has been raised
- 53
- Stated actions linked to this concern
- 75
What this concern includes
Includes inadequate or unembedded escalation procedures and failures by care staff to obtain medical assessment or advice when deterioration, pain or a recognised condition requires it.
What is not included
- Quality of treatment after medical input was obtained
- Routine healthcare access delays outside the care-staff escalation process
- Generic care staffing or training concerns that do not impair clinical escalation
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.
Reports and published responses 48 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to promptly seek medical attention for residents who require it
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sheffcare
Stated actions 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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Sheffcare
Update admissions, falls prevention and risk-assessment policies to require timely assessment, injury monitoring and medical escalation.
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Sheffcare
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
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Sheffcare
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
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Sheffcare
Complete a quality-assurance systems review for linked care plans, risk assessments, falls escalation and care-note updating.
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Concerns raised1
Failure to ensure timely escalation by staff
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions 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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Cwm Taf Morgannwg University Local Health Board
Standardise the Acutely Unwell Course on ESR and increase monthly capacity to 25–30 training places from September 2024.
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Cwm Taf Morgannwg University Local Health Board
Promote the Acutely Unwell Course through posters and staff email and encourage ward managers and senior nurses to book staff.
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Cwm Taf Morgannwg University Local Health Board
Use the full outreach staffing complement to run monthly training and complete Acutely Unwell Course attendance for surgical-ward staff by the end of 2024.
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Concerns raised1
Failure to respond to reported pain with pain relief or medical escalation
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- South Tees 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.4
-
South Tees Hospitals NHS Foundation Trust
Mandate pain assessments at every set of physiological observations through the electronic observation system.
-
South Tees Hospitals NHS Foundation Trust
Incorporate objective pain assessment tools and visual alerts for patients reporting moderate-to-severe pain.
-
South Tees Hospitals NHS Foundation Trust
Monitor compliance with timely pain assessments and reassessments on an ongoing basis.
-
South Tees Hospitals NHS Foundation Trust
Implement the Call 4 Concern initiative, enabling patients and families to request Critical Care Outreach review.
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Concerns raised1
Failure to escalate unsuccessful nasogastric tube placement to appropriate medical expertise
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University College London 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.1
-
University College London Hospitals NHS Foundation Trust
Update the nasogastric-tube policy to cover surgical drainage and escalation of difficult or unsuccessful tube placement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University College London Hospitals NHS Foundation Trust
UCLH states the NG tube was removed appropriately because drainage was low, and that subsequent insertion was inherently difficult and unpredictable.
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Concerns raised1
Failure to recognise when medical attention is required
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sequoia CH Group Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Sequoia CH Group Ltd
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
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Concerns raised1
Delays in calling an ambulance when a resident’s condition requires emergency assistance
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring 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 patients’ deterioration and pain
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure of staff clinical judgement to recognise the need for urgent medical attention in critically ill people
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to seek guidance on managing resistance to turning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Delay in seeking mental health practitioner advice for progressive agitation
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo 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.
Data last updated 7 September 2026