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
Lack of a failsafe mechanism for rapid assessment and escalation after repeated enquiries about the same child health complaint
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to escalate when requested clinical reviews do not occur
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 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
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
High call-holding threshold for triggering CMP 4
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.
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
The Capacity Management and Escalation Plan’s existing triggers are considered safe for managing demand and are reviewed annually.
Stated by East Midlands Ambulance Service NHS Trust
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Concerns raised1
Failure to escalate welfare incidents to the on-call senior manager
This report raised 13 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
Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Establish the Greater Manchester Responding to Crisis Board to oversee cascading, embedding and delivery of the response protocols.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
Stated by NHS Greater Manchester Integrated Care Board
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Action
Issue a memo to all staff increasing awareness of the requirement to seek support from on-call managers.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to escalate calls appropriately after unsuccessful contact
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.2
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Action
Review policies and procedures for establishing contact with patients or callers at scene.
Stated by Welsh Ambulance Services NHS Trust -
Action
Develop a Memorandum of Understanding with police regarding the issue.
Stated by Welsh Ambulance Services NHS Trust
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
Police attendance for ambulance 999 welfare checks is considered inappropriate because police officers lack training for clinical assessment.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Failure of escalation arrangements to provide emergency assessment by critical care-competent staff
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 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
Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Stated by Independent Healthcare Providers Network -
Action
Discuss escalation policies in independent acute hospitals with the CQC.
Stated by Independent Healthcare Providers Network -
Action
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Stated by Independent Healthcare Providers Network
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Action
Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Stated by Independent Healthcare Providers Network
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Stated by Independent Healthcare Providers Network
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Position
There is no evidence that patient transfers are particularly associated with hospitals lacking intensive-care facilities, and national guidance does not require on-site intensive care.
Stated by Independent Healthcare Providers Network -
Position
Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Stated by Independent Healthcare Providers Network
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Concerns raised1
Failure to escalate when an on-call doctor does not attend after a marked change in oxygen saturations
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in alerting hospital security when an inpatient is missing
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 nursing teams about the risks of assuming that an absent patient is not on Trust premises.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure of emergency department on-call arrangements to trigger consultant attendance after long waits
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to alert management to prolonged insulin refusal
This report raised 9 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026