First reported 23 Aug 2013•Latest report 27 May 2026
Definition
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
Distinct published reports
Individual concerns
81
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
103
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.
Department of Health and Social Care6
University Hospitals Sussex NHS Foundation Trust6
NHS England5
Essex Partnership University NHS Foundation Trust4
Mid and South Essex NHS Foundation Trust3
Royal Sussex County Hospital3
University Hospitals Birmingham NHS Foundation Trust3
Lancashire Teaching Hospitals NHS Foundation Trust2
Milton Keynes University Hospital2
Nursing and Midwifery Council2
Recipient name withheld2
Royal College of Obstetricians and Gynaecologists2
Tameside General Hospital2
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
NHS trust45
Healthcare site19
Executive non-departmental public body6
Health professional body6
Ministerial department6
Type not available4
Private limited company3
Health and care professional regulator2
Independent healthcare provider2
Integrated care board2
Local health board2
Company1
Company limited by guarantee1
Coronial office1
Executive agency1
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.
West Yorkshire Eastern
Concerns raised2
Failure to escalate deteriorating postoperative patients to senior clinicians
Lack of clear escalation procedures and training for deteriorating postoperative patients
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 concerns
Each 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.6
Action
Require the consultant anaesthetist to define postoperative care and NEWS thresholds for escalation to critical care outreach.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Implement defined daytime and out-of-hours escalation using consultant contacts, NEWS2 and applicable deteriorating-patient and transfer policies.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Develop a dedicated policy for deteriorating patients cared for at peripheral hospital sites.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Establish a dedicated on-call consultant rota for Chapel Allerton Hospital.
Stated by Leeds Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Extend on-site anaesthetic and recovery-unit cover until 21:00.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Provide rolling staff education and mandatory escalation-pathway and resuscitation training, recording junior doctors’ training on Electronic Staff Records.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Norfolk
Concerns raised1
Failure to accept consultant assistance during the procedure
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 concerns
Each 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
Action
Discuss more patient details with the on-call consultant and obtain advice when uncertain about management.
Stated by Recipient name withheldStated in progressThe respondent said that this action was in progress when they made their response on 1 October 2020.
Inner North London
Concerns raised1
Failure to provide adequate senior specialist support to junior medical staff
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 concerns
Each 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
Action
Reiterate consultant support and escalation expectations to junior hepatology doctors, and update switchboard and ward whiteboard contact details.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2020.
Action
Repeat consultant-support and escalation information during induction training for new junior doctors.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2020.
Bedfordshire and Luton
Concerns raised1
Mismatch between critical care outreach call guidance and nurses’ understanding of the call threshold
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 concerns
Each 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
Action
Deliver direct NEWS2 training to nursing staff, including escalation based on clinical judgement as well as numerical scoring.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
Action
Provide tools and mechanisms for identifying deteriorating patients and clarify escalation routes using clinical experience alongside numerical scoring.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
Action
Use trust-wide clinical updates, shared-learning sessions and safety bulletins to reinforce deterioration recognition and escalation.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 10 November 2019.
West Sussex
Concerns raised1
Failure to escalate assessment and treatment after a serious road traffic collision
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 concerns
Each 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
Action
Develop a trauma-management protocol addressing differing collision-speed accounts, reduced clinical signs in patients using opiates or sedatives, and consideration of trauma calls.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 November 2019.
Manchester South
Concerns raised1
Failure of clinical staff to seek urgent neurology guidance on ongoing prescribing
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to act on NEWS observations and escalate deteriorating patients
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 concerns
Each 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
Action
Expand the Critical Care Outreach service to support immediate escalation from electronic NEWS scores.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Gateshead and South Tyneside
Concerns raised1
Failure to refer women with elevated maternal or fetal growth indicators for Consultant Obstetric care
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Exeter and Greater Devon
Concerns raised1
Failure to directly inform senior clinical staff of disclosed suicide risk
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 concerns
Each 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
Action
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2019.
Action
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2019.
Action
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
Stated by Royal Devon University Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Stated by Royal Devon University Healthcare NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure of junior staff to identify deterioration and escalate to senior staff
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 concerns
Each 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
Action
Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
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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.
