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 raised2
Failure to request obstetric review after 1 hour of active pushing
Failure to request obstetric review for maternal tachycardia
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.
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 report raised NEWS scores to doctors or critical care outreach
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.3
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Action
Improve ward staff familiarity with National Early Warning observations, scoring and escalation through reflection and additional training.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Disseminate National Early Warning System safety guidance to all staff through the weekly Spotlight on Safety message and Patient Observation Policy link.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Circulate a monthly patient-safety bulletin highlighting recognition and escalation of care for deteriorating patients.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to raise immediate concerns with appropriate agencies after no response from an emergency call system user
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.
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 seek urgent hospital security assistance when detention under the Mental Health Act is considered necessary
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.2
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Action
Prepare a joint emergency-department framework and reference document covering risk assessment, capacity, security, observation, documentation and inter-service communication when patients leave.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Action
Prepare a joint emergency-department framework and reference document covering risk, capacity, security, observation, documentation and inter-service communication when patients may leave.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust
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
Informal patients cannot lawfully be prevented from leaving without sufficient grounds for detention or proportionate physical intervention.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust
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Position
The patient did not display behaviour indicating immediate risk, requiring detention, restraint, or an active police search.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust -
Position
The patient was not considered an immediate risk requiring detention, restraint, or an active police search.
Stated by North London NHS Foundation Trust and Whittington Health NHS Trust
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Concerns raised1
Failure to escalate the level of care when there is a deviation from the norm
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.
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 suspend controlled drugs and escalate low blood pressure
This report raised 11 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 unanswered telephone contact attempts to a senior worker
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.1
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Action
Develop a best-practice factsheet formalising contact attempts, escalation, identification of relevant contacts, and communication when referred people cannot be reached.
Stated by Norfolk County Council
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Concerns raised1
Failure to act on Early Warning Observation Chart trigger scores through appropriate escalation of care
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 medical staff after significant hyperglycaemia
This report raised 10 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 take appropriate action after unanswered welfare-check callbacks
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026