Recurring concern
Failure to reliably refer patients to required specialist services
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Request correctionFirst reported 19 Jan 2014•Latest report 4 Feb 2026
What this concern includes
Includes failures in making, recording, tracking or completing clinically required referrals to specialist services, including physiotherapy, occupational therapy, dietetics and specialist nursing, where the referral is needed for assessment, rehabilitation, treatment or safe care.
Not included
- Excludes referral delays or omissions involving a named pathway or service with a more specific established recurring concern, such as mental-health, social-care or district-nursing referrals.
- Excludes failures in specialist assessment or treatment after a referral has been reliably completed and accepted.
- Excludes generic communication, staffing, documentation or care-planning deficiencies unless they directly cause failure to complete a required specialist referral.
- Excludes requests for general advice or informal consultation where no required referral to a specialist service is identified.
- Reports
- 35
- Individual concerns
- 38
- Date range
- 2014–2026
- Stated actions
- 65
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 correctly understand and implement timely TIA Clinic referrals
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.
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
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Action
Reinforce the correct TIA referral pathway with the responsible medical team and disseminate referral resources across the Acute Assessment Unit.
Stated by NHS Suffolk and North East Essex Integrated Care Board and West Suffolk NHS Foundation Trust -
Action
Update the TIA referral guideline, introduce flow diagrams, streamline the referral process, and circulate the materials across relevant clinical teams.
Stated by NHS Suffolk and North East Essex Integrated Care Board and West Suffolk NHS Foundation Trust -
Action
Embed correct TIA referral education in registrar induction and emergency-department training, supported by a new stroke/TIA e-learning video and presentation.
Stated by NHS Suffolk and North East Essex Integrated Care Board and West Suffolk NHS Foundation Trust
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Action
Deliver targeted internal communications to emergency, medical, and other teams reinforcing the TIA referral pathway.
Stated by NHS Suffolk and North East Essex Integrated Care Board and West Suffolk NHS Foundation Trust -
Action
Deliver recurring Trust-wide stroke-awareness communications that reinforce timely TIA referrals, including the planned May 2026 initiative with the Stroke Association.
Stated by NHS Suffolk and North East Essex Integrated Care Board and West Suffolk NHS Foundation Trust
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Concerns raised1
Failure to provide onward referral to dieticians experienced in autism and ARFID
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
Publish guidance for commissioners and providers on children’s eating disorder services, including ARFID care and reasonable adaptations for additional needs.
Stated by NHS England
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Concerns raised1
Failure to consistently identify and make appropriate referrals to the falls team
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.2
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Action
Review the Falls Policy to determine whether more specific referral guidance should be included.
Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare Limited -
Action
Refer every resident who falls to the Falls Team and inform staff of this approach.
Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare Limited
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Concerns raised1
Lack of a standard operating process for referring HOCM 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 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
Circulate guidance to relevant clinicians emphasising timely referral of appropriate patients to a transplant centre.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to ensure doctors promptly refer patients at risk of aspiration to the SALT team
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.
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
Provide swallowing-problem and SALT-referral training to resident doctors, consultants and final-year medical students.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Produce and disseminate a Trust-wide Patient Safety Notice on inpatient referrals to the Speech and Language Therapy team.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Failure to communicate pacemaker extraction referral requirements between specialist and local cardiology services
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.6
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Action
Develop structured Emergency Department discharge communications and built-in referral reminders, while reviewing amendments to the current Emergency Department notes.
Stated by Manchester University NHS Foundation Trust -
Action
Improve Emergency Department HIVE discharge workflows so staff can send discharge letters to relevant healthcare providers, including external cardiology departments.
Stated by Manchester University NHS Foundation Trust -
Action
Develop HIVE tip sheets and video guides on using the Emergency Department discharge navigator’s correspondence function and share them with relevant staff.
Stated by Manchester University NHS Foundation Trust
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Action
Build the HIVE discharge navigator so the correspondence workflow appears in the Emergency Department’s Dispo section.
Stated by Manchester University NHS Foundation Trust -
Action
Reinforce with Cardiology the importance of communicating with other secondary and tertiary care providers to maximise continuity of care.
Stated by Manchester University NHS Foundation Trust -
Action
Provide Cardiology Residents with focused training on copying inpatient discharge letters to relevant healthcare providers and referring patients to available pacemaker extraction services.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Absence of a formal escalation and referral pathway to the anaesthetic team for difficult or unavailable lumbar punctures
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.
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
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Action
Train medical staff to use Theatreman to log escalated procedures, provide pending-procedure visibility and create an audit trail.
Stated by Stockport NHS Foundation Trust -
Action
Formulate the anaesthetic-escalation process for difficult lumbar punctures into a flow chart.
Stated by Stockport NHS Foundation Trust -
Action
Cascade the difficult-lumbar-puncture escalation flow chart to clinicians across medicine and urgent care.
Stated by Stockport NHS Foundation Trust
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Action
Keep patients awaiting lumbar puncture on the acute medical unit until successful completion, recording agreed escalation in Theatreman before any ward transfer.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure to refer patients with a NEWS2 score of 5 and no ceiling of care to the CC Outreach team
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.2
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Action
Publish, implement and spread the PIER Framework to support staff managing physical deterioration and involve patients, families and carers.
Stated by Department of Health and Social Care -
Action
Deliver the “Think Sepsis / Think Outreach” training and poster campaign and include sepsis in Outreach education days.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to make timely referrals to adult neurology services
This report raised 14 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.4
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Action
Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS England -
Action
Develop national neurology guidance and specifications supporting integrated care, including epilepsy services.
Stated by NHS England
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Action
Publish and disseminate a national bundle of care for children and young people with epilepsy, including transition recommendations.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The delay in referral was not attributable to the Trust, which disputes responsibility for the alleged failure to refer Chloe to adult neurology.
Stated by Mid and South Essex NHS Foundation Trust
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Position
After age 16, Chloe’s epilepsy was managed by the Royal London Hospital and her GP, who were responsible for transitional communication.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Lack of systems and processes to ensure completion of alcohol liaison team referrals
This report raised 4 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.4
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Action
Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.
Stated by Adferiad Recovery Ltd -
Action
Implement and roll out the updated service specification to all staff by the end of September 2023.
Stated by Adferiad Recovery Ltd -
Action
Issue communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.
Stated by Betsi Cadwaladr University LHB
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Action
Review the liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.
Stated by Betsi Cadwaladr University LHB
Data last updated 7 September 2026