Recurring concern
Failure to take timely escalation action when safety thresholds are breached
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Request correctionFirst reported 27 Jan 2014•Latest report 16 Mar 2026
What this concern includes
Includes failures to initiate, progress or complete escalation when a defined safety threshold, failed contact or time limit has been reached, including escalation after repeated failed visits, breached response times or comparable triggers requiring senior review, resource allocation or welfare intervention.
Not included
- Excludes the underlying safety concern, staffing shortage or clinical deterioration when no failure to escalate after a defined trigger is identified.
- Excludes failures of ordinary communication or notification where no safety threshold, failed contact or breached time limit required escalation.
- Excludes deficiencies confined to the substantive content of an escalation policy when the policy's operation after a trigger is not the unsafe condition.
- Excludes the existing broader concern about failure to escalate patient-safety concerns to senior oversight when the assertion does not specifically identify a breached threshold, failed contact or time-based escalation trigger.
- Reports
- 62
- Individual concerns
- 65
- Date range
- 2014–2026
- Stated actions
- 84
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 raised1
Failure to return calls from CHOC to NWAS after the third failed contact attempt
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 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 the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
Stated by North West Ambulance Service NHS Trust
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Concerns raised1
Failure to escalate risk after incidents requiring review of observations or ligature controls
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 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
Remind staff and provide additional training and support on escalating incidents and conducting ACCT reviews when risk increases.
Stated by HM Prison and Probation Service
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Concerns raised1
Lack of an electronic observation system for automatically escalating high NEWS scores in A&E
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 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
Implement electronic observations and Early Warning Score visibility across Emergency Department clinical areas using the upgraded patient record and observation machines.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to escalate non-compliance with Level 2 EICO observation requirements
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 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
Review and amend the observation guideline, renaming it Enhanced Therapeutic Observation and Care and strengthening observation, assessment, escalation, family involvement and documentation requirements.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Implement the amended Enhanced Therapeutic Observation and Care guideline across the organisation.
Stated by South Tyneside and Sunderland NHS Foundation Trust -
Action
Evaluate the impact of the Enhanced Therapeutic Observation and Care guideline six months after implementation.
Stated by South Tyneside and Sunderland NHS Foundation Trust
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Concerns raised1
Failure to contact a police supervisor to discuss options when conveyance may affect local officer availability
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.1
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Action
Reiterate to frontline personnel the expectation that officers communicate concerns about redeployment and resource availability to supervising officers.
Stated by Devon & Cornwall Police
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
Whether police should convey patients to hospital is a matter for Devon and Cornwall Police to consider.
Stated by South Western Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure to appropriately escalate NEWS2 scores above seven for specialist advice
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.4
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Action
Update and seek approval for the deteriorating-adult policy and NEWS2 escalation ladder, including family and carer concerns and defined response times.
Stated by NHS Humber Health Partnership -
Action
Deliver Trust-wide simulation training on recognising deterioration, assessing patients and escalating concerns, including learning-disability scenarios.
Stated by NHS Humber Health Partnership -
Action
Provide designated rapid-assessment capacity, escalation clinicians, safety nurses, sepsis champions and streaming-desk nursing cover for deteriorating patients.
Stated by NHS Humber Health Partnership
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Action
Publish and provide the NEWS2 resource pack to support implementation of standardized assessment and escalation for acute illness.
Stated by NHS England
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
Without direct clinical involvement or access to Trust records, NHS England cannot comment directly on David’s care.
Stated by NHS England
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Position
Hull University Teaching Hospitals NHS Trust should respond to concerns about David’s care and treatment.
Stated by NHS England
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Concerns raised1
Failure to escalate increased abdominal pain to a senior doctor within 2 hours
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.
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 a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
Stated by Portsmouth Hospitals University NHS Trust -
Action
Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
Stated by Portsmouth Hospitals University NHS Trust -
Action
Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
Stated by Portsmouth Hospitals University NHS Trust
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Concerns raised1
Failure to escalate unsuccessful contact attempts for a welfare check
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.
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.6
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Action
Contact unallocated service users through a welfare-call system and escalate concerns under new guidance.
Stated by North London NHS Foundation Trust -
Action
Train staff and implement the MaST tool for real-time caseload tracking and prioritisation of high-risk service users.
Stated by North London NHS Foundation Trust -
Action
Use RAG case tracking, weekly allocation meetings and interim manual audits to prioritise and follow up high-risk cases.
Stated by North London NHS Foundation Trust
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Action
Provide staff guidance on RCRP protocols, including escalation within the police system when welfare-check requests are declined.
Stated by North London NHS Foundation Trust -
Action
Clarify whether reported welfare-check arrangements have been completed in future cases.
Stated by GRAY’S INN MEDICAL GROUP -
Action
Discuss welfare-check clarification arrangements with practice management and the clinical lead.
Stated by GRAY’S INN MEDICAL GROUP
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Concerns raised1
Failure to seek urgent clinical assistance for significant per rectum bleeding
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.4
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Action
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
Stated by East Lancashire Hospitals NHS Trust -
Action
Display the ward escalation plan with staged escalation requirements, observation frequencies and staff responsibilities, supported by staff awareness and training.
Stated by East Lancashire Hospitals NHS Trust -
Action
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
Stated by East Lancashire Hospitals NHS Trust
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Action
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised1
Failure to escalate calls when repeated non-response may indicate loss of consciousness
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.
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
Route overdose and poisoning calls through Clinical Navigation for timely clinician review, escalation, further triage and welfare action when specialist triage is delayed.
Stated by North West Ambulance Service NHS Trust
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
When patients do not answer return calls, existing arrangements provide ambulance dispatch and clinician-led judgement on whether categorisation should be upgraded.
Stated by North West Ambulance Service NHS Trust
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Position
Automatic upgrading of every unanswered patient call is not feasible because it would significantly burden ambulance capacity and response-time targets.
Stated by North West Ambulance Service NHS Trust
Data last updated 7 September 2026