Recurring concern
Failure to escalate significant clinical concerns to appropriately senior clinicians
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Request correctionFirst reported 23 Aug 2013•Latest report 27 May 2026
What this concern includes
Includes failures of clinical escalation for significant patient concerns, abnormal findings, changing clinical conditions or treatment problems where escalation to an appropriately senior clinician is required, including obstetric escalation and escalation by junior staff during busy shifts.
Not included
- Excludes generic organisational governance failures where no clinical concern requiring senior clinical review is identified.
- Excludes failures of escalation in non-clinical operational, safeguarding, complaints or emergency-control-room processes.
- Excludes delays in senior review where the failure is solely lack of consultant availability and no escalation deficiency is identified.
- Excludes failures limited to documentation, communication or training unless they directly constitute or undermine escalation of a significant clinical concern.
- Reports
- 72
- Individual concerns
- 81
- Date range
- 2013–2026
- Stated actions
- 103
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 maintain significant clinical information and escalate deterioration to the Consultant Psychiatrist
This report raised 18 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
Save care-related emails to patient records and deliver Trust-wide training on timely records storage.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct every-shift record-keeping audits at the Linden Centre and cascade identified corrective actions.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to ensure medically informed review and escalation of potentially significant NHS 111 information
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.
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 full medical assessment by a senior healthcare professional
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Practice Plus Group is responsible for responding to concerns about healthcare delivery at HMP Hewell.
Stated by HM Prison and Probation Service
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Position
The clinical presentation did not indicate a need for more urgent psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation Trust -
Position
Active clinical observation through ACCT and food refusal processes was sufficient before psychiatric assessment.
Stated by Midlands Partnership University NHS Foundation Trust -
Position
The food and fluid refusal pathway is considered robust and fit for purpose regardless of the reason for refusal.
Stated by Practice Plus Group
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Concerns raised2
Failure to escalate medication concerns to appropriately senior clinicians
Delay and inappropriate escalation of a high NEWS score
This report raised 17 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
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Stated by the Princess Alexandra Hospital NHS Trust -
Action
Include the emergency department escalation process in area-specific orientation for nurses redeployed from their base wards.
Stated by the Princess Alexandra Hospital 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
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS England
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Position
An emergency call was not required because appropriate care was initiated promptly after the raised NEWS score.
Stated by the Princess Alexandra Hospital NHS Trust
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Concerns raised1
Failure to review medication, consider admission, or escalate care for an acutely deteriorating patient
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
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.
Stated by South London and Maudsley NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Position
Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.
Stated by South London and Maudsley NHS Foundation Trust
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Position
Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.
Stated by South London and Maudsley NHS Foundation Trust -
Position
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Stated by South London and Maudsley NHS Foundation Trust -
Position
Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Failure to escalate significant clinical changes for review by appropriately senior clinicians
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 and act on markedly subtherapeutic clozapine levels
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.
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
Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.
Stated by Essex Partnership University NHS Foundation 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
The clozapine assay showed low plasma levels, not sub-therapeutic prescribing, because the prescribed dose remained unchanged.
Stated by Essex Partnership University NHS Foundation Trust
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Position
Clinical assessment and the already scheduled psychiatric review were considered sufficient; no earlier appointment was indicated without evidence of deterioration.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Lack of formal thresholds or protocols for urgent escalation of abnormal observations
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
Operate standardised NEWS2 and POPS assessment within 15 minutes, with senior triage review and immediate escalation to the Emergency Department when indicated.
Stated by Milton Keynes Urgent Care Services (MKUCS
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
Standardised NEWS2/POPS assessment, senior triage review and established escalation pathways are considered sufficient to address abnormal observations.
Stated by Milton Keynes Urgent Care Services (MKUCS
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Concerns raised1
Failure to escalate urgent medication review requests to an appropriate clinician
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.
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
Onward appointment processes are at each GP surgery’s discretion, rather than being determined by the Trust.
Stated by Essex Partnership University NHS Foundation Trust
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Position
The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Lack of clear mechanisms and criteria for escalation to a Consultant Psychiatrist
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.1
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Action
Review the Liaison Service Standard Operating Procedure to incorporate the described consultant-oversight provisions, completing the review by May 2026.
Stated by Essex Partnership University 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
Existing Core 24, multidisciplinary review, referral, escalation and on-call arrangements provide sufficient Consultant oversight for liaison patients.
Stated by Essex Partnership University NHS Foundation Trust
Data last updated 7 September 2026