First reported 19 Jan 2014•Latest report 4 Feb 2026
Definition
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
Distinct published reports
Individual concerns
38
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
65
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.
NHS England4
Department of Health and Social Care3
Care Quality Commission2
Hc-One Limited2
Manchester University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
Adferiad Recovery1
Barts Health NHS Trust1
Bedfordshire Hospitals NHS Foundation Trust1
Belong Limited1
Betsi Cadwaladr University LHB1
Bristol NHS Foundation Trust1
Brunswick Ward at Lindridge1
Castlehill Specialist Care Centre1
Cornerstone Family Practice1
NHS trust19
Healthcare site7
Executive non-departmental public body4
Integrated care board4
Ministerial department3
Health and social care service regulator2
Multi-service care provider2
Private limited company2
Type not available2
Care-home operator1
Community interest company1
English metropolitan district council1
Health professional body1
Health professional committee1
Independent healthcare provider1
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.
Cumbria
Concerns raised1
Failure to make promised referrals to relevant specialist services
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
Review and discuss Hadrian Unit discharge processes with staff to improve communication of onward referrals.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
Action
Record onward referrals and receiving-team acceptance on the electronic MDT proforma, with monthly compliance audits.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The discharge included planned follow-up, with ongoing support from the Cumbria East Crisis Team and planned referrals to other services.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Berkshire
Concerns raised1
Lack of a clear UKFAR referral requirement after unsuccessful resuscitation
This report raised 8 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.
Surrey
Concerns raised1
Failure to make timely referrals from general practice to secondary medical services for febrile seizures
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
Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 March 2023.
Action
Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 31 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing national guidance is considered sufficient for managing febrile seizures.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Stated by Royal College of Emergency MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Failure to refer allergy patients to an allergy clinic
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.
Black Country
Concerns raised1
Failure to complete required referral to the physiotherapy team
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
Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
Stated by Castlehill Specialist Care CentreStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Action
Conduct management reviews and assess available evidence about the provider’s falls-management concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CQC will not progress a criminal investigation because the evidence does not meet the required threshold of proving avoidability beyond reasonable doubt.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Delays in patients being referred to the cardiology clinic
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.1
Action
Implement the changed NT-proBNP testing and referral pathway, including urgency thresholds for echocardiography and heart failure services.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 26 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There were no delays; investigations and referrals followed correct, timely processes and pathways, so the reported cardiology-timescale risk did not arise in this case.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Bedfordshire and Luton
Concerns raised1
Failure of the standard referral system to reliably transmit Bedford Neurologist referrals
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure to consider gastroenterology referral after clinical deterioration
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
Change the consultant’s clinical practice in response to learning from the case.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Action
Share learning with colleagues through a grand round.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Action
Produce and circulate a standard operating procedure for managing suspected upper gastrointestinal bleeding.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Manchester South
Concerns raised1
Lack of a system to follow up unanswered specialist referrals
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
Route tissue-viability referrals by email or telephone, confirm them by summary email and next-day calls, and track follow-up using diary and audit-sheet prompts.
Stated by Olea Care LtdStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Change Tissue Viability referrals from fax to email and add prompts to follow up referrals not actioned within two working days.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Require Fernlea staff to obtain email read receipts, telephone the service the following day, and record confirmed visit dates.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
Action
Complete the extended comprehensive inspection of Fernlea Care Home, examining pressure-ulcer management and management oversight.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2019.
Avon
Concerns raised1
Failure to refer patients with multiple developmental, sensory and physical conditions for investigation of an underlying disorder by a clinical geneticist
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.9
Action
Develop a patient information leaflet explaining lead clinician responsibility for patients attending regional clinics.
Stated by Bristol NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2020.
Action
Finalise and adopt Principles of Shared Care for Endocrine and a corresponding patient information leaflet by the end of March 2020.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Formalise regional-clinic agreements through Service Level Agreements defining accountability and responsibility.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Review paediatric communication and care-coordination processes and recommend improvements to Trust governance groups.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Hold a paediatric meeting with the Regional Clinical Genetics Service to review referral guidance and disseminate it to the paediatric clinical teams.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Provide twice-yearly educational contact from the Regional Clinical Genetics Service at established paediatric clinical education meetings.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Assess paediatric clinicians’ individual needs for genetic-care updates and support any additional training costs.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Establish a regular Regional Clinical Genetics advice point during or after monthly clinics.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 January 2020.
Action
Provide Genomics nurse attendance at a paediatric departmental meeting to explain the Regional Genetic Service.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 January 2020.
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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.
