Recurring concern
Unreliable dissemination of safety-critical clinical guidance and learning
- Reports that mention this concern
- 14
- Times this concern has been raised
- 14
- Stated actions linked to this concern
- 16
What this concern includes
Includes failures to disseminate, cascade, communicate or make accessible safety-critical clinical guidance, policy or practice changes, revised training, best practice and lessons learned to the clinicians, teams or care units responsible for applying them, including the anchor's clinical-care policy and practice changes and comparable cross-unit or cross-clinician dissemination failures.
What is not included
- Excludes failures in the substantive content, evidence base or updating of clinical guidance where dissemination is not the unsafe condition.
- Excludes failures to implement or embed a change after it was reliably disseminated, unless the report also identifies a dissemination failure.
- Excludes generic communication, record-keeping, training or organisational-learning deficiencies without a material safety-critical clinical guidance, policy-change, best-practice or learning dissemination context.
- Excludes dissemination processes bounded to a distinct named system, hazard or statutory pathway when that named concern provides the more specific supported boundary.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 14 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Shortcomings in dissemination of clinical-care policy and practice changes
Linked response
- Blackpool Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Blackpool Teaching Hospitals NHS Foundation Trust
Implement structured dissemination of clinical policy changes through central coordination, digital alerts, manager briefings, safety huddles, meetings, rapid training and e-learning.
-
Blackpool Teaching Hospitals NHS Foundation Trust
Refine policy document control, approval, risk stratification, communication, intranet access, training linkage and compliance oversight through established committees and supporting teams.
-
Blackpool Teaching Hospitals NHS Foundation Trust
Roll out Alertive to issue critical messages, record staff acknowledgements, and subsequently scope its use for cascading policy documents.
-
Concerns raised1
Failure to ensure relevant NICE guidance reaches applicable organisations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
National Institute for Health and Care Excellence
Reflect on the report and incorporate lessons into NICE’s approach to disseminating future guidance.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
National Institute for Health and Care Excellence
Local commissioners and providers are responsible for reviewing new NICE guidance and considering its relevance within their settings.
-
Concerns raised1
Failure to ensure all doctors receive learning-point discussions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- George Eliot Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
George Eliot Hospital NHS Trust
Develop shared server and intranet locations so staff can access incident-learning reports and written materials.
-
Concerns raised1
Lack of national provision for sharing maternity induction-of-labour learning
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to effectively communicate key changes in clinical practice and advice
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to disseminate revised Clinical Risk Assessment training to treating clinicians
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Birmingham and Solihull Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Birmingham and Solihull Mental Health NHS Foundation Trust
Establish and operate a working group to devise a pilot of revised clinical risk training.
-
Concerns raised1
Failure to establish whether information about olanzapine-associated drug reaction with eosinophilia and systemic symptoms is known to clinicians nationally
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to communicate urgent and emergency guidance clarifications to doctors and relevant NHS staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- St George'S University Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
St George'S University Hospitals NHS Foundation Trust
Communicate the updated guidance and case learning to the wider organisation through the communications department.
-
St George'S University Hospitals NHS Foundation Trust
Highlight the policy changes at Information Governance Committee meetings and in all Information Governance training sessions.
-
Concerns raised1
Lack of circulation of call termination guidance to call handling staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- North West Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
North West Ambulance Service NHS Trust
Revise the call-termination guidance and circulate it to all EOC supervisors.
-
North West Ambulance Service NHS Trust
Brief all call takers individually on the revised guidance and obtain signed confirmation that they understand it.
-
North West Ambulance Service NHS Trust
Establish a reminder system to prompt periodic recirculation of call-termination guidance to call takers.
-
Concerns raised1
Failure to share asthma-care learning continuously across medical professionals
This report raised 24 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
NHS England
Operate the National Paediatric Asthma Collaborative to coordinate clinicians, commissioners and voluntary organisations in improving children’s asthma care.
-
NHS England
Share and implement learning from the review of paediatric asthma deaths across the country.
-
NHS England
Share Healthy London Partnership learning, standards, clearer messaging and E-asthma tools across NHS commissioners to support active asthma-management measures.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026