Recurring concern
Unreliable admission assessment of patients
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Request correctionFirst reported 30 Jul 2013•Latest report 27 May 2026
What this concern includes
Includes failures of the admission or immediate receiving-assessment process, including omitted or delayed assessment, failure to complete required assessment components, failure to reconcile relevant pre-admission information, and failure to make necessary clinical information available to admission clinicians.
Not included
- Excludes failures limited to maintaining or retrieving clinical records when no admission-assessment impact is identified.
- Excludes pre-discharge, post-discharge, outpatient or routine ongoing assessments that are not part of admission or immediate receiving assessment.
- Excludes condition-specific assessment pathways, such as VTE, bowel-obstruction or mental-health assessment, when that named pathway supplies the more specific supported concern.
- Excludes failures occurring after an adequate admission assessment where the problem is subsequent monitoring, treatment, escalation or care planning.
- Reports
- 27
- Individual concerns
- 28
- Date range
- 2013–2026
- Stated actions
- 18
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
Delays in doctor-led admission clerking
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
Failure to act on available nutritional requirements advice at admission
This report raised 6 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
Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.
Stated by Sheffield Teaching Hospitals NHS Foundation Trust -
Action
Provide wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.
Stated by Sheffield Teaching Hospitals 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
COVID-19 operational pressures prevent implementing all planned safety changes in the near future.
Stated by Sheffield Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Clerking and risk assessment of frail elderly transfer patients out of hours
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.
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 knowledge of the clinical effects of substantial hepatic compromise during haemorrhagic admission
This report raised 13 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 admission recording system to make obtaining carer and family information mandatory
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
Use an active Care Notes care-planning field to record information sought from carers or family.
Stated by Devon Partnership NHS Trust -
Action
Activate a Care Notes risk-assessment area recording carers’ and family members’ views.
Stated by Devon Partnership NHS 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
A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.
Stated by Devon Partnership NHS Trust
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Concerns raised1
Clerking of acute patients by a medical student
This report raised 10 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 assess the significance of patients’ existing comorbidity medication
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 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 a clear diagnostic pathway and monitoring plan on admission
This report raised 6 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
Establish and ratify a small bowel obstruction surgical pathway covering diagnostic priorities and monitoring for this patient group.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Lack of documented risk assessments at admission onto Mason Unit
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Unavailability of Community medical records at hospital admission
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.
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
Electronic community health records cannot be provided locally until national pilot studies are completed and the service is extended to hospital emergency settings.
Stated by Swansea Bay University Local Health Board
Data last updated 7 September 2026