First reported 20 Dec 2013•Latest report 28 May 2025
Definition
What this concern includes
Includes failures to assign, communicate, maintain or exercise clear accountability for health and safety controls across strategic, operational and property or service-level functions, where unclear ownership can leave safety risks unmanaged.
Not included
Excludes failures limited to a specific risk assessment, inspection, maintenance task or remedial action when accountability for the wider health and safety control arrangement is not deficient.
Excludes generic organisational governance, leadership or responsibility concerns with no direct health and safety control or safety consequence.
Excludes ordinary disagreements about responsibility where a clear accountable owner exists and the control is operating reliably.
Reports
17
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
28
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 England2
Welsh Government2
ABTA Ltd1
Agd Equipment Limited1
Ashford Borough Council1
Belmarsh Prison1
Bounce Til I Die1
Bridgend County Borough Council1
Caister-on-Sea Parish Council1
Capita Business Services Ltd1
Capita PLC1
Cardiff Council1
Children's Commissioner for Wales1
CMBC Supply Limited1
Construction Plant-hire Association1
Ministerial department5
Company3
NHS trust3
Private limited company3
Devolved government2
English district council2
Executive non-departmental public body2
Public limited company2
Charity regulator1
English county council1
English unitary authority1
Executive agency1
Independent healthcare provider1
Local authority1
Local health board1
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to rapidly resolve responsibility for housing cuckooed tenants who become effectively homeless
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
Direct managers and supervisors to use the Escalation of Professional Differences Procedure and Guidance.
Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 6 June 2025.
Action
Ensure all managers and supervisors demonstrate understanding and application of the escalation procedure by August 2025.
Stated by Cornwall CouncilStated plannedThe respondent said that this action was planned when they made their response on 6 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Council cannot dictate individual social housing providers’ operational policies for resolving cuckooing concerns.
Stated by Cornwall CouncilOutside remitThe respondent said that this matter was outside its role or authority.
North Wales (East and Central)
Concerns raised1
Failure of central oversight of local safety execution
This report raised 16 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.7
Action
Continue examining TSA’s safeguarding and governance concerns, including assessing corrective work and requesting supporting information.
Stated by The Charity CommissionStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Action
Ensure TSA and its affiliated charities understand which safety improvements the Commission considers essential.
Stated by The Charity CommissionStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Action
Build and operate a permanent internal Audit and Assurance team to audit local charities, monitor compliance and report nationally.
Stated by The Scout AssociationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Action
Introduce a movement-wide assurance framework for local safety compliance monitoring and auditing.
Stated by The Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Action
Increase safety, adventurous-activities and training staffing capacity, including recruiting new safety roles and agreeing a permanent structure.
Stated by The Scout AssociationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Action
Review and improve support, training, communication and accountability for County and District leadership and Trustees.
Stated by The Scout AssociationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Action
Continue assessing the case and practicalities for further regulation of out-of-school settings.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Department cannot comment on the Scout Association’s internal structure, workings, or implementation of internal policies and procedures.
Stated by Department for EducationOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Scout Association and the Charity Commission are expected to address matters concerning internal operations and charity trustees’ legal duties, respectively.
Stated by Department for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Failure to allocate responsibilities and powers for training and travellator-operation competence in cleaning contracts
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 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.3
Position
Formal transport safety intervention is the Office of Rail and Road’s responsibility as the independent rail safety regulator.
Stated by Department for TransportRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Day-to-day London Underground operations and processes fall outside departmental powers and are accountable to the London Mayor through TfL.
Stated by Department for TransportOutside remitThe respondent said that this matter was outside its role or authority.
Position
KONE is responsible for training its staff and suppliers who undertake inching activities.
Stated by Transport for LondonRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure of police and health-trust partnership working to allocate responsibility for patient retrieval
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 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
Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023.
Action
Establish an external partner delivery group with health and social care partners to clarify responsibilities and support Right Care, Right Person implementation.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023.
Action
Continue joint discussions with the MPS and local health stakeholders on AWOL responses and respective organisational roles.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Existing Affinity Protocols, Joint Responsibility Agreements and national frameworks sufficiently define police and health partners’ roles for absconded patients.
Stated by Metropolitan Police ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Retrieving sectioned patients who leave medical settings is generally a healthcare responsibility unless locating or detaining them engages core policing duties.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Health partners generally remain responsible for transporting located patients back to hospital, rather than police providing transport.
Stated by Metropolitan Police ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational decisions about missing-person investigations are outside the Home Office’s authority.
Stated by Home OfficeOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for operational missing-person decisions rests with individual police forces and their Chief Officers.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The MPS Affinity Protocol is considered sufficient because it reflects the NPCC framework for missing persons from healthcare settings.
Stated by Home OfficeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Birmingham and Solihull
Concerns raised2
Lack of a clearly identifiable person responsible for reviewing and investigating health and safety incidents
Lack of clear lines of responsibility for organisation-wide health and safety risk assessment and incident information gathering
This report raised 17 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
Direct incident reports to medical and health-and-safety leaders and provide them with joint investigation accountability.
Stated by Capita PLC and Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
Action
Operate joint Army–Capita health-and-safety governance forums and shared risk-management processes.
Stated by Capita PLC and Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 30 December 2019.
Norfolk
Concerns raised1
Failure to establish responsibility for the coastline section
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.
Nottinghamshire
Concerns raised1
Lack of accountability between professionals for consent
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The described vetting and consent arrangements are expected to resolve accountability between professionals, so no additional action is identified.
Stated by Nottingham University Hospitals NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Newcastle upon Tyne
Concerns raised1
Failure to document the division of safety responsibilities with another provider
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.
Central and South East Kent
Concerns raised1
Lack of clarity about authority responsibility for the area
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Lack of clear responsibility for identifying and ameliorating staffing and acuity risks
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.4
Action
Recruit additional midwifery staff and monitor midwifery and medical staffing monthly.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
Action
Complete a Birth Rate Plus assessment of workforce needs for the new unit.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
Action
Implement an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2019.
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Includes failures to assign, communicate, maintain or exercise clear accountability for health and safety controls across strategic, operational and property or service-level functions, where unclear ownership can leave safety risks unmanaged.
