First reported 5 Sep 2013•Latest report 30 Jan 2026
Definition
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.
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
Reports
48
Distinct published reports
Individual concerns
53
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
75
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.
Care Quality Commission7
Recipient name withheld4
Care UK2
National Institute for Health and Care Excellence2
Nursing and Midwifery Council2
Royal Sussex County Hospital2
Abbey Care Village1
Adbolton Hall1
Angel Solutions (UK) Ltd1
Belle Green Court1
Belong Limited1
Bolton Borough Council1
Bury Borough Council1
Calderdale Royal Hospital1
Cann House Care Home1
NHS trust13
Residential care home8
Health and social care service regulator7
Nursing home7
Private limited company7
Type not available7
English metropolitan district council5
Healthcare site5
Care-home operator2
Executive non-departmental public body2
Health and care professional regulator2
Multi-service care provider2
Nursing-home operator2
Clinical commissioning group1
Company limited by guarantee1
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.
West Yorkshire Eastern
Concerns raised1
Lack of clear escalation procedures and training for deteriorating postoperative patients
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 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
Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Black Country
Concerns raised1
Delays in seeking medical review after head injury
This report raised 12 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.
Central and South East Kent
Concerns raised1
Failure to escalate reported pain for further medical advice
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.
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
Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
Stated by Charing Dale LimitedStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Stated by Charing Dale LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner West London
Concerns raised1
Failure to seek clinical assessment when staff note deterioration in residents' health
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 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.
Manchester South
Concerns raised1
Failure to recognise and escalate significant pressure-ulcer deterioration promptly
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.
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.7
Action
Provide wound-management refresher training to registered nurses and care staff.
Stated by Olea Care LtdStatus at responseThe respondent said that this action was partly complete when they made their response on 31 December 2019.
Action
Embed React to Red wound-management training in induction for all new staff.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Notify the GP of all tissue-viability referrals and include wound management in weekly GP ward rounds.
Stated by Olea Care LtdStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.
Action
Implement electronic pressure-ulcer photography at identification and regular intervals to monitor deterioration.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2019.
Surrey
Concerns raised1
Failure to seek medical attention for patients’ pressure sores
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 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.
West Sussex
Concerns raised1
Delays in seeking out-of-hours medical advice and requesting GP review
This report raised 13 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.1
Action
Implement the GP and NHS 111 escalation procedure, including urgency assessment, clear clinical communications and service-level auditing.
Stated by Shaw Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
North West Kent
Concerns raised1
Failure to escalate to the medical team
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.
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
Implement the approved blood-glucose monitoring guideline, including traffic-light interpretation, hypoglycaemia management and escalation procedures.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Provide monthly induction training for clinical support workers, registered nurses and junior doctors on diabetic monitoring, equipment, escalation and referrals.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Deliver targeted staff training and share case learning on testing, abnormal-result response and escalation to medical or diabetes teams.
Stated by Maidstone and Tunbridge Wells NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Develop and introduce connected blood-glucose and ketone meters with real-time dashboard escalation, replacing existing meters and training staff.
Stated by Maidstone and Tunbridge Wells NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Inner South London
Concerns raised1
Failure to escalate to medical care or refer
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Delays in seeking medical attention when service users deteriorate
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.
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
Review and develop training to help staff recognise deterioration, question medical professionals, and identify triggers for seeking further advice.
Stated by Persona Care And Support LimitedStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Monitoring of unwell service users is limited to what is appropriate for Elmhurst’s social-care registration and staff’s non-medical qualifications.
Stated by Persona Care And Support LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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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.
