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.
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.
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
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Stated by the Shrewsbury and Telford Hospital NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS EnglandRedirects 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.
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
Use a discharge process requiring follow-up appointments when needed and documenting confirmation in patient records.
Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 June 2025.
Action
Conduct regular ward audits to monitor compliance with the follow-up appointment process.
Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 June 2025.
Cheshire
Concerns raised1
Failure to book follow-up appointments for patients presenting with mental health difficulties
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
Consider GP booking of follow-up appointments where this forms part of a patient's safety plan.
Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
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.
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
Written correspondence was considered adequate and effective; no evidence showed alternative contact methods would have increased appointment attendance.
Stated by Cwm Taf Morgannwg University Local Health BoardExisting 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.
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
Review the One Stop Shop breast clinic appointments process.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
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.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Department cannot comment on the two-week follow-up because it was a local arrangement.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Ashford & St Peters NHS Trust is responsible for responding fully to the local follow-up concern.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Matters of concern 1 and 2 will be addressed by the President of the Royal College of Radiologists.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The organisation cannot comment on Ashford Hospital’s follow-up appointment system.
Stated by Royal College of NursingUnable 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.
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
Develop and assess a Lorenzo enhancement for sending appointment correspondence to nominated next of kin or carers according to patient preference.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Issue a patient safety alert keeping communication with next of kin and carers a primary staff focus during system changes.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Update the community services standard operating procedure with Lorenzo guidance and expectations for recording communication preferences in care documentation.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Action
Continue the Think Carer and Family programme to improve consistent recording of carers and next of kin, including Trust-wide rollout from October 2025.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Ensure future assessments consider short-term memory difficulties and record communication preferences in combined assessments, recovery plans and safety plans.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
No single technical solution can fully mitigate appointment communication risk; mitigation requires a range of actions.
Stated by Norfolk and Suffolk NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The proposed Lorenzo enhancement cannot be implemented until clinical safety and information governance compliance are confirmed.
Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The new electronic patient record is delayed because procurement must follow the nationally mandated purchasing route.
Stated by Norfolk and Suffolk NHS Foundation TrustUnable 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.
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
The fracture was minimally displaced and would not have required restricted mobilisation or orthopaedic follow-up if identified.
Stated by the Princess Alexandra Hospital NHS TrustDisputes 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.
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 the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
Stated by Hull University Teaching Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Stated by Care Quality CommissionRedirects 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.
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
Develop a standard operating procedure for monitoring potentially cancerous lesions, including information transfer between teams.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Develop a risk-stratification process within clinical teams for patients who cancel appointments or do not attend.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
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.
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
Provide AMS CSU patients with discharge notes, booked follow-up appointments, wound-care plans, medication or supplies, and community-support instructions.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Amend the electronic discharge-note template to include required discharge information and advice.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
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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.
