First reported 16 May 2016•Latest report 18 Mar 2026
Definition
What this concern includes
Includes failures in hospital processes for developing, maintaining, publishing, accessing, communicating, understanding or applying operational protocols for emergency situations, including the anchor's absent hospital emergency protocols and comparable failures where hospital staff cannot readily locate or use relevant emergency protocols.
Not included
Excludes emergency-response failures outside hospital settings unless the assertion explicitly concerns the same hospital emergency-response protocol system.
Excludes generic staff training, communication, staffing or equipment deficiencies unless they directly impair hospital emergency-response protocols.
Excludes failures in the clinical treatment or emergency response after relevant hospital protocols were available, understood and applied.
Excludes protocols for a separately named hospital pathway or system, such as pre-alerts, Code Blue or hospital-at-night coordination, where that named concern provides the more specific supported boundary.
Reports
2
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2016–2026
First to latest report issue date
Stated actions
9
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.
Care Quality Commission1
Circle Health Group Limited1
General Medical Council1
Nuffield Health1
Royal College of Radiologists1
Royal Surrey County Hospital1
Company limited by guarantee1
Health and care professional regulator1
Health and social care service regulator1
Healthcare site1
Health professional body1
Private limited company1
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.
Essex
Concerns raised2
Insufficient staff understanding of emergency protocols
Unavailability of relevant emergency protocols at the point of need
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.
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
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Further develop the major-haemorrhage training module to clarify end-to-end processes and differences from NHS pathways.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Roll out mandatory emergency-protocol induction for site leaders, night coordinators and senior nursing staff, including role responsibilities.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Monitor emergency training compliance, emergency-document availability, MyStaff policy access and scenario outcomes through audit and governance processes.
Stated by Nuffield HealthStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Operate MyStaff as a centralised platform for accessible Group and local policies, update alerts and critical-policy readership analytics.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Use policy-access and readership analytics to assure Consultant and staff engagement with critical emergency documentation.
Stated by Nuffield HealthStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Update induction and practising-privileges renewal checklists to cover MyStaff access and locating local emergency policies.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
All staff, including the site manager, had received training on the transfusion and major haemorrhage policies in force at the time.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Regulation 28 concerns did not contribute to the patient’s death.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Absence of operational protocols for hospital emergency situations
This report raised 22 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
Review and update the Elective and Non-Elective Transfer Policy, agreeing emergency transfer processes with Royal Surrey County Hospital and making them available to relevant staff.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Action
Establish a local SOP requiring critically ill patients to move automatically to the theatre recovery area for comprehensive monitoring and anaesthetic support.
Stated by Circle Health Group LimitedStated completedThe respondent said that this action was complete when they made their response on 16 May 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The hospital had an emergency transfer policy and facilities to stabilise critically ill patients before transfer.
Stated by Circle Health Group LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures in hospital processes for developing, maintaining, publishing, accessing, communicating, understanding or applying operational protocols for emergency situations, including the anchor's absent hospital emergency protocols and comparable failures where hospital staff cannot readily locate or use relevant emergency protocols.
