Recurring concern
Unsafe implementation and oversight of service changes
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Request correctionFirst reported 31 Oct 2014•Latest report 14 Oct 2025
What this concern includes
Includes failures in the dedicated governance and implementation of material service or practice changes, including inadequate supervision or control, insufficient consultation where safety is affected, unclear responsibility, delayed completion and failure to demonstrate that changes have been implemented.
Not included
- Excludes routine operational changes with no identified safety consequence or deficient safety control.
- Excludes failures limited to implementing a separately identified safety action, clinical policy, operational protocol or named pathway where that more specific concern is the supported boundary.
- Excludes generic organisational leadership, staffing, audit or governance deficiencies unless they directly impair the safe implementation or oversight of a service change.
- Excludes failures limited to verifying the effectiveness of an already implemented change when no broader service-change implementation or oversight failure is identified.
- Reports
- 10
- Individual concerns
- 12
- Date range
- 2014–2025
- Stated actions
- 12
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
Risk of loss or dilution of prescribing safety nets during electronic system changes
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.2
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Action
Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Stated by Lewisham and Greenwich NHS Trust
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Concerns raised1
Failure to embed serious incident learning and changes in frontline practice
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.
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 additional training and reflection sessions for the nurse and her line manager regarding the case context.
Stated by Leicestershire Partnership NHS Trust -
Action
Review causal factors and deliver additional training to the team on reading clinical records before Safe and Well calls and clinical decisions.
Stated by Leicestershire Partnership NHS Trust -
Action
Update the Central Access Point Standard Operating Procedure to require clinicians to review records, assess referrals and prioritise triage calls by risk, urgency and availability.
Stated by Leicestershire Partnership NHS Trust
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Action
Redesign the Safe and Well template with staff input, obtain clinical safety sign-off and make it available within the electronic patient record.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Failure to provide advance notice of changes requiring beach safety mobilisation
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
Existing regular communication between DfT, MCA and RNLI addresses advance notice for lifeguard recruitment and training.
Stated by Cabinet Office
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Concerns raised1
Failure to formally plan and consider amendments to birth-choice guidance
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.1
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Action
Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Delays in achieving safety changes within self-set timeframes
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.
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
Track serious incident investigation actions in the Datix patient safety system and audit completion timeframes and supporting evidence.
Stated by Betsi Cadwaladr University LHB -
Action
Review historic serious incident action plans and verify evidence for each action through an appointed clinician.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to implement substantive safety changes in residential care homes
This report raised 19 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
Hospital systems and processes are not considered generally relevant to residential services, so sweeping changes are not necessarily warranted.
Stated by Jeesal Residential Care Services Limited
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Concerns raised3
Failure to consult staff and residents about substantial changes
Failure to manage the mental-health impact of sudden service changes
Inadequate supervision and control of service changes
This report raised 17 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 demonstrate changes in practice and procedure
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
Introduce management and governance controls including daily checks, incident reviews, walkarounds, resident-of-the-day reviews, online documentation, and wider audits.
Stated by Zinnia Healthcare Limited
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Concerns raised1
Failure to change the service to address identified clinical risks
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
Lack of audit and assurance of departmental safety changes
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.2
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Action
Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.
Stated by South London and Maudsley NHS Foundation Trust
Data last updated 7 September 2026