Recurring concern
Failure to maintain follow-up of patients who disengage from care
- Reports that mention this concern
- 23
- Times this concern has been raised
- 23
- Stated actions linked to this concern
- 29
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.
What is 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.
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.
Reports and published responses 23 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- Cardiff & Vale University LHB
- Welsh Government
Stated actions 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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Cardiff & Vale University LHB
Implement and operate a standard procedure for clerically validating Barrett’s surveillance and other endoscopy waiting lists.
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Cardiff & Vale University LHB
Schedule patients overdue since January for appointments to address and clear the backlog.
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Cardiff & Vale University LHB
Determine surveillance intervals using evidence-based recall periods, overdue calculations and disease-specific coding aligned with BSG guidance.
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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Welsh Government
Secondary care should continue managing Barrett’s Oesophagus surveillance recalls; GP recalls or prompts would duplicate responsibilities and cause confusion.
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Welsh Government
The relevant health board is responsible for investigating surveillance-list management and strengthening records and processes to prevent future deaths.
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Welsh Government
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.
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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.
Linked response
- North East London 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
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North East London NHS Foundation Trust
Review zoning practice across four boroughs and produce a revised case-review template focused on recent face-to-face contact.
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North East London NHS Foundation Trust
Review and finalise the Missed Appointments Policy with stronger guidance for disengagement, unsuccessful contact and escalation of concerns.
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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.
Linked response
- North London 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.3
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North London NHS Foundation Trust
Review the DNA policy to formalise escalation after two consecutive missed appointments.
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North London NHS Foundation Trust
Implement the revised DNA policy through staff training and monitor its impact through a quality-improvement project.
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North London NHS Foundation Trust
Organise additional London Care Record training to improve information sharing and notification of GPs when concerns or disengagement arise.
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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.
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
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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
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Hull University Teaching Hospitals NHS Trust
Concerns about points 2 and 3 relate to primary care rather than the Trust’s responsive responsibilities.
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NHS England
Providers involved in Linda’s care should address the specific care concerns, provide further information, and identify related learning.
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Care Quality Commission
Oversight of the GP practice is assigned to the integrated care board, while findings inform CQC’s regulatory response.
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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.
Linked response
- Greater Manchester Mental Health 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
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Greater Manchester Mental Health NHS Foundation Trust
Use MaST across CMHT supervision and zoning meetings to identify gaps in contact and support.
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Greater Manchester Mental Health NHS Foundation Trust
Implement and disseminate the Managing Did Not Attend and Cancellations policy across clinical services, with defined escalation requirements.
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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.
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.
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.
Linked response
- Bexley Medical Group
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
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Bexley Medical Group
Contact mental health patients who miss hospital outpatient appointments to establish reasons and support attendance.
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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.
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.
Linked response
- Avenue House Nursing and Care Home
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
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Avenue House Nursing and Care Home
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
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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Avenue House Nursing and Care Home
After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026