Recurring concern
Unsafe updating of clinical policies and guidance
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Request correctionFirst reported 23 Oct 2013•Latest report 24 Oct 2025
What this concern includes
Includes failures in the dedicated clinical-policy and guidance-updating process, including identifying the need for revision, resolving ambiguity, incorporating external guidance, approving changes, communicating them and implementing associated safety actions.
Not included
- Excludes generic staff training, communication, documentation or governance deficiencies unless they directly concern updating or implementing clinical policies and guidance.
- Excludes operational protocol changes that are not clinical policies or guidance, including non-clinical procedures and local operational instructions.
- Excludes failures to follow an otherwise current and clear policy or guidance when no deficiency in updating, revising or implementing the policy itself is identified.
- Excludes deficiencies in the substantive clinical care, equipment or staffing arrangements where no clinical-policy or guidance-updating failure is asserted.
- Reports
- 21
- Individual concerns
- 26
- Date range
- 2013–2025
- Stated actions
- 31
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 raised2
Ineffective communication of foreign-object insertion policy and guidance to staff
Lack of specific, clear and robust policy guidance for managing foreign-object insertion
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.
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
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Action
Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Disseminate the approved foreign-bodies guideline to staff involved in managing patients presenting with deliberately inserted foreign bodies.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure of commissioning bodies to fully consider or implement NICE ME guidance
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.
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
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Action
Develop and publish ME/CFS guidance recommending assessment and skills for specialist services.
Stated by National Institute for Health and Care Excellence -
Action
Support development of the cross-government ME/CFS delivery plan.
Stated by National Institute for Health and Care Excellence -
Action
Explore whether to prescribe a specialised service for people with very severe ME/CFS.
Stated by Department of Health and Social Care
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
Implementation of NICE guidance through service commissioning and delivery is the responsibility of the relevant NHS body.
Stated by National Institute for Health and Care Excellence
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Position
NICE guidelines are not mandatory, although commissioners are expected to take them fully into account and work towards implementation.
Stated by Department of Health and Social Care
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Concerns raised1
Absence of a specific policy for management of Ryles tubes
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 current practice and develop a Trust-wide policy for managing Ryles tubes used for aspiration drainage.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Present and publish the Ryles tube policy and communicate it to all staff through a Trust-wide safety message.
Stated by Oxford University Hospitals NHS Foundation Trust
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Concerns raised1
Ambiguity in the venous thromboembolism policy
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.1
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Action
Remove unclear VTE assessment information from the Physical Healthcare Policy and publish an update directing staff to the VTE policy.
Stated by East London 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 separate VTE policy is unambiguous and aligned with NICE guidelines, although VTE information in the Physical Healthcare Policy is unclear.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to formally plan and consider amendments to birth-choice guidance
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
Review and align the Birth Choices and home birth guidelines to clarify referral pathways, team responsibilities, and inclusion in birth-planning discussions.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Failure to ensure timely updating and incorporation of clinical policies and guidance
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.
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 keep sepsis protocols and policies up to date
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.1
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Action
Update and issue the Trust-wide sepsis policy, aligned with current NICE guidance and incorporating HIVE-related practice changes.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Failure to maintain aligned and current guidance on IV fluid bolus volumes for children presenting with shock
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.2
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Action
Review relevant NICE guidance for alignment with the 2021 UK Resuscitation Council paediatric advanced life support guidance.
Stated by National Institute for Health and Care Excellence -
Action
Review the 2021 UK Resuscitation Council guideline and consider whether CG84 and related NICE guidance need updating.
Stated by National Institute for Health and Care Excellence
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Concerns raised1
Failure to adopt accelerated N-acetylcysteine administration into a standard operating protocol
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.
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 update streaming guidance in line with relevant learning and guidance
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.1
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Action
Review and submit joint streaming guidance incorporating THINK AORTA learning for governance approval.
Stated by Barts Health NHS Trust and North East London NHS Foundation Trust
Data last updated 7 September 2026