First reported 30 Jan 2013•Latest report 23 Oct 2025
Definition
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.
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.
Reports
42
Distinct published reports
Individual concerns
46
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
46
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.
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
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.
Inner West London
Concerns raised1
Failure to arrange follow-up appointments before discharge
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 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.3
Action
Circulate reminders requiring relevant medical colleagues to book necessary outpatient follow-up appointments before discharge.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 10 March 2023.
Action
Share a further reminder requiring outpatient follow-up appointments to be booked before discharge.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 10 March 2023.
Action
Continue monthly audits of pre-discharge outpatient appointment booking until three consecutive months achieve 100% compliance.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2023.
Herefordshire
Concerns raised1
Discharge of service users after missed appointments without adequate follow-up
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 concerns
Each 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
Position
Discharging a patient after a missed appointment was considered sufficient under IAPT policy, with contact attempts and re-referral information provided.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure to offer face-to-face consultation or arrange follow-up
This report raised 11 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.2
Action
Offer face-to-face appointments to patients presenting with new mental-health issues.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Review patient follow-up timescales and require GPs to book follow-up appointments rather than asking patients to call.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Remote consultations during the COVID-19 pandemic were consistent with NHS England guidance, although face-to-face appointments were required from May 2021.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
Face-to-face consultation was not offered because pandemic advice was to avoid face-to-face appointments where possible.
Stated by Farnham Park Health Group and Recipient name withheldUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire (Western)
Concerns raised1
Failure to provide patients with written reminders of forthcoming appointments
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
Send appointment confirmation letters and 48-hour reminder text messages for appointments booked on the hospital management system.
Stated by Spire Harpenden HospitalStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Regulation 28 concern is factually incorrect because the evidence did not establish that Spire lacked customary written appointment reminders.
Stated by Spire Harpenden HospitalDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Failure to offer follow-up appointments for allergy-related issues
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.
Liverpool and the Wirral
Concerns raised1
Failure to follow up missed appointments for investigation of neutropenia
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 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.6
Action
Schedule and clinically annotate ward-attender appointments electronically to track attendance and record outcomes.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Require consultant clinical review and documented follow-up for every child not brought to a scheduled outpatient or ward-attender appointment.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Audit the outpatient non-attendance pathway and review cases where children were not clinically reviewed.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Revise the Did Not Attend policy into a corporate Was Not Brought policy incorporating required safeguards and best-practice principles.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Conduct monthly audits of adherence to the updated Was Not Brought policy and processes, escalating breaches through governance and incident-management arrangements.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Surrey
Concerns raised2
Unclear responsibility for re-booking appointments after non-attendance
Failure to ensure re-booking of appointments after non-attendance for newly referred patients
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 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.2
Action
Assign the Referral Co-ordinator responsibility for booking further initial assessment appointments after non-attendance.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2021.
Action
Audit compliance with the strengthened referral follow-up arrangements over the forthcoming months.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Manchester South
Concerns raised1
Lack of follow-up review appointments for prescribed medication
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.2
Action
Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Action
Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
Manchester South
Concerns raised1
Failure to make a follow-up appointment at discharge
This report raised 5 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.
Gloucestershire
Concerns raised1
Failure to follow up patients after missed mental health appointments
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.
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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.
