Failure to take timely escalation action when safety thresholds are breached
First to latest report 27 Jan 2014 — 16 Mar 2026
Reports that mention this concern
62
Times this concern has been raised
65
Stated actions linked to this concern
84
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Department of Health and Social Care6
NHS England5
Barts Health NHS Trust3
Care Quality Commission3
North West Ambulance Service NHS Trust3
East Midlands Ambulance Service NHS Trust2
Essex County Council2
Essex Partnership University NHS Foundation Trust2
Manchester University NHS Foundation Trust2
South East Coast Ambulance Service NHS Foundation Trust2
University Hospitals Sussex NHS Foundation Trust2
Adbolton Hall1
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bedford Prison1
NHS trust39
Ministerial department7
Executive non-departmental public body5
Healthcare site5
English county council4
Health and social care service regulator3
Nursing home3
Prison or young offender institution3
Type not available3
English metropolitan district council2
Local health board2
London borough council2
Multi-service care provider2
Police force2
Private limited company2
Reports and published responses 62 reports
See individual reports that have raised this concern, and the actions taken in response
Plymouth, Torbay and South Devon
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
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.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Tameside and Glossop Integrated Care NHS Foundation Trust
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Northamptonshire
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.
Linked response
East Midlands Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
East Midlands Ambulance Service NHS Trust
The Capacity Management and Escalation Plan’s existing triggers are considered safe for managing demand and are reviewed annually.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
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.
Linked responses
NHS Greater Manchester Integrated Care Board
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
NHS Greater Manchester Integrated Care Board
Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
NHS Greater Manchester Integrated Care Board
Establish the Greater Manchester Responding to Crisis Board to oversee cascading, embedding and delivery of the response protocols.
NHS Greater Manchester Integrated Care Board
Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
Pennine Care NHS Foundation Trust
Issue a memo to all staff increasing awareness of the requirement to seek support from on-call managers.
Gwent
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.
Linked response
Welsh Ambulance Services NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Welsh Ambulance Services NHS Trust
Review policies and procedures for establishing contact with patients or callers at scene.
Welsh Ambulance Services NHS Trust
Develop a Memorandum of Understanding with police regarding the issue.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Welsh Ambulance Services NHS Trust
Police attendance for ambulance 999 welfare checks is considered inappropriate because police officers lack training for clinical assessment.
No action considered necessaryThe respondent said that no further action was needed.
Berkshire
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.
Linked response
Independent Healthcare Providers Network
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Independent Healthcare Providers Network
Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Independent Healthcare Providers Network
Discuss escalation policies in independent acute hospitals with the CQC.
Independent Healthcare Providers Network
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Independent Healthcare Providers Network
Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Independent Healthcare Providers Network
Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Independent Healthcare Providers Network
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.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Independent Healthcare Providers Network
Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
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.
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust
Remind nursing teams about the risks of assuming that an absent patient is not on Trust premises.
Manchester South
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.