Recurring concern

Failure to escalate significant clinical concerns to appropriately senior clinicians

First to latest report 23 Aug 2013 — 27 May 2026

Reports that mention this concern
72
Times this concern has been raised
81
Stated actions linked to this concern
103

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.

What is 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 and published responses 72 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Leicester City and South Leicestershire

    AI-generated summary

    Joan Mary Jones · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joan Mary Jones, a resident of a care home with Alzheimer's dementia, became unwell on 23 September 2012 and later deteriorated following an aspiration episode. She died on 1 October 2012; the inquest recorded bilateral bronchopneumonia due to locally advanced adenocarcinoma of the large bowel and Alzheimer's dementia. Concerns included failure to escalate her care and failure to communicate relevant information to attending healthcare professionals, resulting in a missed opportunity to treat and an inappropriate care package.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to escalate care when clinically required

    Wider context from the report

    “(1) The staff did not escalate Mrs Jones' care when they should have done (2) The staff did not communicate all that was known to them and therefore attending health care professionals were unable to make fully informed decisions (3) Due to the lack of communication, an appropriate package of care was not put in place for Mrs Jones (4) These omissions (failure to escalate and the lack of communication with other attending health care professionals) together or alone, could in future circumstances cause or contribute to death. ”

    Source location

    Joan Mary Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. West Yorkshire (East)

    AI-generated summary

    JILL FELICITY SINSON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jill Felicity Sinson had schizophrenia, an anxiety-related disorder, non-epileptic seizures, and a history of self-harm and suicidal tendencies. She was last seen alive on 3 September 2012 and was found lifeless at her home on 10 September 2012; life was pronounced extinct by paramedics. The concerns included inadequate GP monitoring, failure to review or refer her after a GP surgery consultation, insufficient consideration of her medical history when prescribing medication unsupervised, and failure to act appropriately on correspondence from her Consultant Psychiatrist.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to arrange necessary General Practitioner review or Consultant Psychiatrist referral

    Wider context from the report

    “(2) When the Deceased was seen at the GP surgery by a Staff Nurse on the 3rd July 2012 – (a) the Deceased’s presentation on that occasion was such as to necessitate a review by a GP and/or referral to the Deceased’s Consultant Psychiatrist, but no such review and/or referral was considered, and (b) due regard was not paid to the Deceased’s computerised medical records prior to and/or in the course of consulting with the Deceased on that occasion, as information provided by the Deceased to the said Staff Nurse was fundamentally incorrect which was apparent from earlier entries in the Deceased’s said records ”

    Source location

    JILL FELICITY SINSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026