First reported 23 Oct 2013•Latest report 24 Oct 2025
Definition
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
Distinct published reports
Individual concerns
26
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
31
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.
Department of Health and Social Care4
National Institute for Health and Care Excellence3
Pennine Acute Hospitals NHS Trust2
University Hospitals of Derby and Burton NHS Foundation Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
British Association of Perinatal Medicine1
College of Clinical Perfusion Scientists1
East London NHS Foundation Trust1
HCA Healthcare UK The Portland Hospital1
Liverpool Women'S NHS Foundation Trust1
Medicines and Healthcare products Regulatory Agency1
National Institute for Cardiovascular Outcomes Research1
National Patient Safety Agency1
NHS trust14
Executive non-departmental public body4
Health professional body4
Ministerial department4
Executive agency2
Healthcare site2
Health-system partnership1
Local health board1
Medicines and medical devices regulator1
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.
West London
Concerns raised1
Failure of hospital policy and practice to clarify attending personnel roles during epidural siting
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
Implement clarified midwifery and anaesthetic responsibilities, including maintaining fetal monitoring and providing backup support during epidural insertion.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Action
Update the Fetal Monitoring and Epidural Analgesia in Labour policies to clarify staff responsibilities during epidural insertion.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
Action
Disseminate the clarified responsibilities through team meetings, multidisciplinary circulation and skills-and-drills training.
Stated by The Portland Hospital for Women and ChildrenStated completedThe respondent said that this action was complete when they made their response on 9 February 2021.
City of London
Concerns raised1
Failure to keep national Mycobacterium Chimaera risk guidance and web information updated
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
Further update the risk estimates and publish them by September 2021.
Stated by College of Clinical Perfusion Scientists and National Institute for Cardiovascular Outcomes Research and Public Health England and Society for Cardiothoracic Surgery in Great Britain and IrelandStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Action
Cascade updated risk estimates through clinical networks to professionals informing or consenting patients and investigating or diagnosing infections.
Stated by College of Clinical Perfusion Scientists and National Institute for Cardiovascular Outcomes Research and Public Health England and Society for Cardiothoracic Surgery in Great Britain and IrelandStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Action
Forward requests to NHS England to agree responsibility and a timetable for updating healthcare guidance and NHS website information.
Stated by College of Clinical Perfusion Scientists and National Institute for Cardiovascular Outcomes Research and Public Health England and Society for Cardiothoracic Surgery in Great Britain and IrelandStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The risk estimate was not inaccurate because it measured infection risk using data on all reported cases, not only deaths.
Stated by College of Clinical Perfusion Scientists and National Institute for Cardiovascular Outcomes Research and Public Health England and Society for Cardiothoracic Surgery in Great Britain and IrelandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS England is responsible for updating guidance and the NHS website, so the requests will be forwarded to it.
Stated by College of Clinical Perfusion Scientists and National Institute for Cardiovascular Outcomes Research and Public Health England and Society for Cardiothoracic Surgery in Great Britain and IrelandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Hampshire, Portsmouth and Southampton
Concerns raised3
Failure to maintain awareness of revised National Institute for Health and Care Excellence guidance on head-injury scanning
Failure of the head-injury policy to include patients receiving low-dose anticoagulants within the 8-hour computerised tomography scan criterion
Failure of the head-injury policy to reflect revised National Institute for Health and Care Excellence guidance
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
Amend and launch the head-injury policy to require CT scanning within eight hours for patients receiving therapeutic anticoagulants, including DOACs.
Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Disseminate the updated head-injury policy and key NICE changes to clinical teams and publish it on the staff intranet.
Stated by University Hospital Southampton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 January 2021.
Action
Continue ensuring CT scanning within eight hours for patients receiving prophylactic enoxaparin who develop clinical signs or symptoms after a fall, and for patients receiving therapeutic anticoagulants.
Stated by University Hospital Southampton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NICE is expected to clarify whether prophylactic anticoagulants should trigger the same scanning requirements as therapeutic anticoagulants.
Stated by University Hospital Southampton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Patients receiving prophylactic enoxaparin are not routinely scanned after falls without clinical signs suggesting bleeding.
Stated by University Hospital Southampton NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Universal CT scanning for patients receiving prophylactic enoxaparin could overwhelm scanning capacity and delay scans for patients who require them.
Stated by University Hospital Southampton NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Lack of NHS Trust requirements for internal UVC policies and procedures to comply with BAPM 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 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
NICE considers no direct action necessary at present, while logging the concerns for consideration during the next NG154 update.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
East London
Concerns raised1
Visipaque procedure policy failing to require contrast documentation and preliminary checks
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to incorporate the significance of head injury in patients undergoing haemodialysis or with significant uraemia due to renal failure into relevant NICE guidelines
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
Log the concerns with the guideline surveillance team for consideration when the head injury guidance is next reviewed.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 7 September 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing head injury guideline does not need amendment because its bleeding-disorder risk factor and CT assessment recommendations already address the concern.
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.
Manchester South
Concerns raised1
Failure to maintain an up-to-date Status Epilepticus protocol
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 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
Revise the Trust’s Status Epilepticus Policy using current clinical guidance.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 February 2016.
Manchester North
Concerns raised1
Difficulty for Trusts to change guidance without external guidance improvement
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
Revise and ratify the assisted vaginal delivery guideline with clarified consultant presence, abandonment criteria, terminology and traction requirements.
Stated by The Pennine Acute HospitalsStated in progressThe respondent said that this action was in progress when they made their response on 31 March 2015.
Action
Issue the consultant-presence requirement for all instrumental delivery trials and audit compliance across both inpatient sites.
Stated by The Pennine Acute HospitalsStated completedThe respondent said that this action was complete when they made their response on 31 March 2015.
Action
Review the Trust guideline again after receiving the RCOG recommendations.
Stated by The Pennine Acute HospitalsStated plannedThe respondent said that this action was planned when they made their response on 31 March 2015.
Action
Send the coroner’s report to the RCOG to communicate the concerns about ambiguity in its maternity guidance.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 31 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
RCOG is responsible for addressing concerns about its professional guidance.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local maternity and neonatal providers are responsible for determining how services should be delivered in their areas.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised3
Failure to update guidance to require specific examination of the QTc interval in all pre-operative ECGs
Failure to update pre-operative assessment guidance to require consideration of drug-induced LQTS before omitting a 12 lead ECG
Failure to update guidance to require 12 lead ECG recording and QTc examination for patients receiving drugs at high or intermediate risk of inducing cardiac arrest in LQTS
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.
Worcestershire
Concerns raised1
Failure to provide clear and consistent policy on compelling psychiatric patients to attend hospital
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.
Pin
Get email alerts
Request correction
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.
