Recurring concern
Failure to maintain follow-up of patients who disengage from care
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Request correctionFirst reported 23 Jul 2013•Latest report 1 Oct 2025
What this concern includes
Includes failures of a patient follow-up or contact process involving non-compliance, non-contact, disengagement or loss to follow-up, including failures to initiate further contact, escalate concerns or maintain continuity across services.
Not included
- Excludes routine delays in follow-up where patient disengagement or non-contact is not material to the concern.
- Excludes failures concerning a specific diagnostic, treatment or appointment process unless the report identifies loss of patient follow-up as the shared unsafe condition.
- Excludes generic staffing, training, documentation or governance deficiencies not explicitly tied to maintaining follow-up of disengaged patients.
- Reports
- 23
- Individual concerns
- 23
- Date range
- 2013–2025
- Stated actions
- 29
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
Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders
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.3
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Action
Implement and operate a standard procedure for clerically validating Barrett’s surveillance and other endoscopy waiting lists.
Stated by Cardiff & Vale University LHB -
Action
Schedule patients overdue since January for appointments to address and clear the backlog.
Stated by Cardiff & Vale University LHB -
Action
Determine surveillance intervals using evidence-based recall periods, overdue calculations and disease-specific coding aligned with BSG guidance.
Stated by Cardiff & Vale University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Secondary care should continue managing Barrett’s Oesophagus surveillance recalls; GP recalls or prompts would duplicate responsibilities and cause confusion.
Stated by Welsh Government
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Position
The relevant health board is responsible for investigating surveillance-list management and strengthening records and processes to prevent future deaths.
Stated by Welsh Government -
Position
The Welsh Government cannot investigate surveillance management because it lacks access to health-board records, systems and processes, and lacks the relevant power and expertise.
Stated by Welsh Government
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Concerns raised1
Failure to review risk of harm when contact is lost
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 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
Review zoning practice across four boroughs and produce a revised case-review template focused on recent face-to-face contact.
Stated by North East London NHS Foundation Trust -
Action
Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.
Stated by North East London NHS Foundation Trust
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Concerns raised1
Failure to follow up repeated failed clinical encounters
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.3
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Action
Review the DNA policy to formalise escalation after two consecutive missed appointments.
Stated by North London NHS Foundation Trust -
Action
Implement the revised DNA policy through staff training and monitor its impact through a quality-improvement project.
Stated by North London NHS Foundation Trust -
Action
Organise additional London Care Record training to improve information sharing and notification of GPs when concerns or disengagement arise.
Stated by North London NHS Foundation Trust
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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 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
Share the review findings with CQC’s Primary and Community Care operations team for consideration in its regulatory response.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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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 Trust
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Position
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
Stated by NHS England -
Position
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
Stated by Care Quality Commission
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Concerns raised1
Lack of escalation following disengagement from community services
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 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
Use MaST across CMHT supervision and zoning meetings to identify gaps in contact and support.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Implement and disseminate the Managing Did Not Attend and Cancellations policy across clinical services, with defined escalation requirements.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Lack of systems to prevent people who do not engage being left solely in family care
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 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 defined steps when a patient cannot be contacted
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.
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 identify and address hospital loss to follow-up during medication review
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
Contact mental health patients who miss hospital outpatient appointments to establish reasons and support attendance.
Stated by Bexley Medical Group
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Concerns raised1
Lack of effective follow-up action when high-risk patients with learning disabilities disengage
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.
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 of the Falls Prevention Service to proactively follow up required input
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 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
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
Stated by Avenue House Nursing and Care Home
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
After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
Stated by Avenue House Nursing and Care Home
Data last updated 7 September 2026