First reported 22 Aug 2014•Latest report 16 Jun 2025
Definition
What this concern includes
Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable critical-care outreach for deteriorating patients’ and satisfy this evidence boundary: Three distinct reports directly support outreach-team non-attendance in emergency departments, limited outreach authority causing treatment delay, and outreach unavailability because of staffing. Excludes general ICU escalation, doctor-to-doctor discussion and specialty-training assertions; retire position 250 and move its shared outreach assertion here so it is counted once.
Not included
Excludes general hospital staffing, training or capacity deficiencies not specifically tied to critical-care capability for deteriorating patients.
Excludes critical-care bed-capacity shortages where the concern is availability of beds rather than critical-care expertise, escalation or outreach support.
Excludes failures in definitive treatment after appropriate critical-care input has been obtained.
Excludes unrelated emergency-response, referral or clinical-management failures without a material critical-care capability or escalation component.
Excludes manifestations outside the manually reviewed boundary: Three distinct reports directly support outreach-team non-attendance in emergency departments, limited outreach authority causing treatment delay, and outreach unavailability because of staffing. Excludes general ICU escalation, doctor-to-doctor discussion and specialty-training assertions; retire position 250 and move its shared outreach assertion here so it is counted once.
Reports
7
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
10
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.
Barts Health NHS Trust1
Bedfordshire Hospitals NHS Foundation Trust1
Great Western Hospitals NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
NHS England1
Royal College of Obstetricians and Gynaecologists1
Royal Sussex County Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
Tameside General Hospital1
University Hospitals Sussex NHS Foundation Trust1
NHS trust6
Healthcare site2
Executive non-departmental public body1
Health professional body1
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.
East London
Concerns raised1
Failure of the Critical Care Outreach Team to attend A&E for deteriorating patients
This report raised 8 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.2
Position
CCOT cannot currently review acutely unwell, undifferentiated Emergency Department patients because it lacks the required skills and resources.
Stated by Barts Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A critical care in-reach registrar with consultant intensivist access provides responsive Emergency Department support, although it does not replace full CCOT presence.
Stated by Barts Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Delays in escalating deteriorating maternity patients for senior and critical care review
This report raised 15 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.8
Action
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Provide guidance defining circumstances requiring consultant attendance in acute obstetric and gynaecological care, including maternal collapse and major haemorrhage.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
Action
Implement the OBS UK obstetric bleeding care bundle covering risk assessment, quantitative blood-loss measurement, escalation, and rapid clotting tests.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
Action
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Embed deterioration recognition, concealed-bleeding assessment and escalation training in PROMPT, induction, local teaching, drills and written staff communications.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Adopt a rota requiring junior registrars to pair with senior registrars and establish supervision and risk-mitigation arrangements when the intended skill mix is unavailable.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Manchester South
Concerns raised1
Unavailability and insufficient capacity of the Critical Care Outreach team
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 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
Maintain a 24-hour, seven-day MERIT service staffed by senior anaesthetic clinicians to provide emergency critical-care support.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The concerns fall under the Trust’s remit rather than NHS England’s functions.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing outreach absence procedures, staffing oversight and MERIT support provided alternative safeguards when an outreach practitioner was redeployed.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bedfordshire and Luton
Concerns raised1
Limited critical care outreach authority and initial medical response causing potential delays in life-saving measures
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.1
Action
Operate a multidisciplinary critical care outreach team with trained staff, authority to develop treatment plans, medical access and consultant review of referred patients.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A doctor is not required for the critical care outreach team’s initial response because its multidisciplinary model complies with national standards.
Stated by The TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Critical care outreach nurses do not request CT scans; scan requests are escalated to an appropriate doctor.
Stated by The TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to explore alternative escalation routes when ICU outreach is unavailable
This report raised 12 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.
Wiltshire and Swindon
Concerns raised1
Failure to empower nursing staff to refer critically ill patients to the Critical Care Outreach Team
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to refer patients to the Critical Care Outreach Team at required NEWS thresholds
This report raised 8 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.
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Includes only assertions that directly instantiate the manually reviewed condition ‘Unreliable critical-care outreach for deteriorating patients’ and satisfy this evidence boundary: Three distinct reports directly support outreach-team non-attendance in emergency departments, limited outreach authority causing treatment delay, and outreach unavailability because of staffing. Excludes general ICU escalation, doctor-to-doctor discussion and specialty-training assertions; retire position 250 and move its shared outreach assertion here so it is counted once.
