Unreliable arrangement and communication of patient appointments and follow-up
First to latest report 30 Jan 2013 — 23 Oct 2025
Reports that mention this concern
42
Times this concern has been raised
46
Stated actions linked to this concern
46
What this concern includes
Includes failures of the patient-facing appointment communication and follow-up process, including reminders, contact after non-attendance, communication of appointment requirements, and communication or arrangement of required repeat or subsequent appointments.
What is not included
Excludes failures to provide the clinical assessment or treatment itself where appointment communication is not the concern.
Excludes generic record-keeping, staffing or information-transfer failures unless they directly make patient appointment or follow-up communication unreliable.
Excludes communication unrelated to arranging, confirming, changing or following up a patient appointment.
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.
Department of Health and Social Care5
NHS England4
Care Quality Commission3
Greater Manchester Health and Social Care Partnership2
Midlands Partnership University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
Pennine Care NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
CAMHS East – Cross Street Clinic1
Care UK1
Central and North West London NHS Foundation Trust1
City Health Care Partnership CIC1
Community Mental Health Recovery Services (Surrey and Borders Partnership)1
County Durham and Darlington NHS Foundation Trust1
NHS trust27
Healthcare site13
Ministerial department6
Executive non-departmental public body4
Integrated care board4
Health and social care service regulator3
Health professional body3
Health and care professional regulator2
Health-system partnership2
Multi-service care provider2
Prison or young offender institution2
Type not available2
Clinical commissioning group1
Community interest company1
Coronial office1
Reports and published responses 42 reports
See individual reports that have raised this concern, and the actions taken in response
Shropshire, Telford and Wrekin
Concerns raised1
Failure to arrange cardiology follow-up after discharge
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
the Shrewsbury and Telford Hospital NHS 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
the Shrewsbury and Telford Hospital NHS Trust
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
the Shrewsbury and Telford Hospital NHS Trust
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
the Shrewsbury and Telford Hospital NHS Trust
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
the Shrewsbury and Telford Hospital NHS Trust
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
the Shrewsbury and Telford Hospital NHS Trust
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
County Durham and Darlington
Concerns raised1
Failure to arrange follow-up appointments after discharge
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
County Durham and Darlington 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.2
County Durham and Darlington NHS Foundation Trust
Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
County Durham and Darlington NHS Foundation Trust
Conduct regular ward audits to monitor compliance with the follow-up appointment process.
Cheshire
Concerns raised1
Failure to book follow-up appointments for patients presenting with mental health difficulties
Linked response
Royal College of General Practitioners
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
Royal College of General Practitioners
Consider GP booking of follow-up appointments where this forms part of a patient's safety plan.
South Wales Central
Concerns raised1
Failure to consider alternative contact methods for urgent gynaecology appointments
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
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Cwm Taf Morgannwg University Local Health Board
Written correspondence was considered adequate and effective; no evidence showed alternative contact methods would have increased appointment attendance.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised2
Failure to clearly communicate required follow-up to families
Failure to complete scheduled two-week follow-up after aspiration
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Ashford and St Peter'S Hospitals NHS Foundation Trust
Department of Health and Social Care
Royal College of Nursing
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Ashford and St Peter'S Hospitals NHS Foundation Trust
Review the One Stop Shop breast clinic appointments process.
Ashford and St Peter'S Hospitals NHS Foundation Trust
Develop and finalise a standard operating procedure standardising Breast One Stop Shop Clinic follow-up, including earlier review where needed, and provide it to the court.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Department of Health and Social Care
The Department cannot comment on the two-week follow-up because it was a local arrangement.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Department of Health and Social Care
Ashford & St Peters NHS Trust is responsible for responding fully to the local follow-up concern.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Ashford and St Peter'S Hospitals NHS Foundation Trust
Matters of concern 1 and 2 will be addressed by the President of the Royal College of Radiologists.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Royal College of Nursing
The organisation cannot comment on Ashford Hospital’s follow-up appointment system.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Suffolk
Concerns raised1
Failure to consistently inform agreed next-of-kin contacts of appointments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Norfolk and Suffolk 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.5
Norfolk and Suffolk NHS Foundation Trust
Develop and assess a Lorenzo enhancement for sending appointment correspondence to nominated next of kin or carers according to patient preference.
Norfolk and Suffolk NHS Foundation Trust
Issue a patient safety alert keeping communication with next of kin and carers a primary staff focus during system changes.
Norfolk and Suffolk NHS Foundation Trust
Update the community services standard operating procedure with Lorenzo guidance and expectations for recording communication preferences in care documentation.
Norfolk and Suffolk NHS Foundation Trust
Continue the Think Carer and Family programme to improve consistent recording of carers and next of kin, including Trust-wide rollout from October 2025.
Norfolk and Suffolk NHS Foundation Trust
Ensure future assessments consider short-term memory difficulties and record communication preferences in combined assessments, recovery plans and safety plans.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Norfolk and Suffolk NHS Foundation Trust
No single technical solution can fully mitigate appointment communication risk; mitigation requires a range of actions.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk and Suffolk NHS Foundation Trust
The proposed Lorenzo enhancement cannot be implemented until clinical safety and information governance compliance are confirmed.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Norfolk and Suffolk NHS Foundation Trust
The new electronic patient record is delayed because procurement must follow the nationally mandated purchasing route.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to book fracture clinic follow-up
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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
the Princess Alexandra Hospital NHS Trust
The fracture was minimally displaced and would not have required restricted mobilisation or orthopaedic follow-up if identified.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
East Riding and Hull
Concerns raised1
Absence of GP follow-up triggers for recently discharged patients with worsening conditions and missed routine appointments
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Hull University Teaching Hospitals NHS Trust
NHS England
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
Care Quality Commission
Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Hull University Teaching Hospitals NHS Trust
Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Worcestershire
Concerns raised1
Lack of a clear system for following up missed important urology appointments and meeting treatment targets
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Worcestershire Acute Hospitals NHS 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.2
Worcestershire Acute Hospitals NHS Trust
Develop a standard operating procedure for monitoring potentially cancerous lesions, including information transfer between teams.
Worcestershire Acute Hospitals NHS Trust
Develop a risk-stratification process within clinical teams for patients who cancel appointments or do not attend.
North Yorkshire and York
Concerns raised1
Failure to arrange follow-up appointments at discharge
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Leeds Teaching Hospitals NHS 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.2
Leeds Teaching Hospitals NHS Trust
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Leeds Teaching Hospitals NHS Trust
Amend the electronic discharge-note template to include required discharge information and advice.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.