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 escalate changes in leave risk
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.
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
Implement an inpatient care framework with named-nurse responsibilities and personalised leave plans reviewed by clinical teams.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review multidisciplinary safety huddles and improve handovers through a nurse-in-charge checklist and task allocation.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to escalate a significant number of falls sustained by a frail older person
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.
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 promptly escalate care to a high dependency unit despite a NEWS score of 8
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 eligible emergency department patients for consultant review
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
Implement a policy empowering any multiprofessional team member to escalate delayed assessment or transfer to the consultant on call.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Deliver an education programme on escalation for delayed assessment or transfer from August 2023.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Deliver direct teaching and display laminated posters in acute surgical areas at all acute sites by 31 October 2023.
Stated by University Hospitals Birmingham NHS Foundation 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
Responsibility for addressing emergency department patient volume rests with the Department of Health and Social Care.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Lack of escalation when assessment and discharge planning requests are not answered
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
Operate a monthly Mental Health Resolution Forum to resolve liaison issues between Children and Families, EWMHS and Tier 4 specialist commissioning.
Stated by Essex County Council
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 acknowledged shortcomings were not causation or contributory factors in Molly’s death.
Stated by Essex County Council
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Concerns raised1
Delay in calling the ITU team during critical emergencies
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
Delays in alerting police when psychiatric patients fail to return from leave
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.4
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Action
Update the Missing Informal Patient Policy with a risk-assessment checklist and flow chart for managing patients who fail to return from leave.
Stated by Central and North West London NHS Foundation Trust -
Action
Establish hourly ward accounting of patients during each shift, with responsibility allocated to the nurse in charge.
Stated by Central and North West London NHS Foundation Trust -
Action
Review Datix recording of police contact during AWOL incidents to monitor reporting timeliness and escalate unnecessary delays.
Stated by Central and North West London NHS Foundation Trust
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Action
Update the Missing Informal Patient Policy to specify police-contact information required in SystmOne and Datix records.
Stated by Central and North West London NHS Foundation 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 reporting after voluntary-leave failures need not be immediate or automatic; individualized risk assessment and ward-team discussion determine the response.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to appropriately escalate abnormal vital signs
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 by counsellors to disclose serious eating-disorder risks when breaching confidentiality is justified
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
Review member resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Stated by British Association For Counselling And Psychotherapy -
Action
Continue reviewing guidance and resources on confidentiality, competence limits, safeguarding, duty of care and eating disorders.
Stated by British Association For Counselling And Psychotherapy -
Action
Continue highlighting critical professional guidance through member bulletins, publications, the website and member events.
Stated by British Association For Counselling And Psychotherapy
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
It is unclear whether breaching confidentiality would have saved the client’s life because her situation was already known to medical services and her partner.
Stated by British Association For Counselling And Psychotherapy
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Concerns raised2
Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails
Lack of escalation following disengagement from community services
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.
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
Use MaST across CMHT supervision and zoning meetings to identify gaps in contact and support.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Implement and disseminate the Managing Did Not Attend and Cancellations policy across clinical services, with defined escalation requirements.
Stated by Greater Manchester Mental Health NHS Foundation 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
The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.
Stated by Greater Manchester Mental Health NHS Foundation Trust
Data last updated 7 September 2026