Recurring concern
Unreliable escalation policy for care concerns
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Request correctionFirst reported 1 Aug 2013•Latest report 31 Mar 2026
What this concern includes
Includes failures in the named or directly corresponding escalation-policy process, including policy clarity, dissemination, staff understanding, embedding, use when triggers arise and assurance that escalations are made through the required route.
Not included
- Excludes generic escalation failures where no escalation policy or equivalent bounded policy process is identified.
- Excludes generic staff training, communication or staffing deficiencies unless they directly impair understanding or use of the escalation policy.
- Excludes failures in the substantive response after an escalation has been correctly made.
- Excludes escalation processes belonging to a separately named system or pathway when that system provides the more specific supported boundary.
- Reports
- 35
- Individual concerns
- 35
- Date range
- 2013–2026
- Stated actions
- 59
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 use the escalation policy
This report raised 11 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
Implement and operate an escalation policy enabling midwives to contact the on-call Obstetric Consultant and Senior Midwife directly.
Stated by Cwm Taf Morgannwg University Local Health Board
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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.
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
Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Stated by Independent Healthcare Providers Network -
Action
Discuss escalation policies in independent acute hospitals with the CQC.
Stated by Independent Healthcare Providers Network -
Action
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Stated by Independent Healthcare Providers Network
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Action
Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Stated by Independent Healthcare Providers Network
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Stated by Independent Healthcare Providers Network
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Position
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.
Stated by Independent Healthcare Providers Network -
Position
Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Stated by Independent Healthcare Providers Network
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Concerns raised1
Lack of a challenge or escalation process for rejected psychiatric referrals
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
Develop and implement a Stockport escalation process and protocol for rejected referrals and disagreements about psychiatric assessment.
Stated by Pennine Care 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
Evidence showed RAID planned and made a psychiatric referral, although the outpatient referral was not accepted.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Lack of care assistant understanding and systems for escalating choking episodes to SALT
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.
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 individuals’ unmet needs
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
Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.
Stated by Addiction Dependency Solutions
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Concerns raised1
Unclear process for escalation to consultant level and critical care
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
Develop an implementation plan for rolling out the National Early Warning System independently of the delayed electronic patient record launch.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Inconsistent policies governing NEWS observation escalation
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
Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Lack of clear procedures for Care Assistants escalating health concerns
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.
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
Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.
Stated by Care Quality Commission -
Action
Remind Support Workers how to escalate health concerns and seek external professional advice through staff training, induction, supervision, reviews and audits.
Stated by Belong
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 provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.
Stated by Care Quality Commission
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Position
Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.
Stated by Care Quality Commission
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Concerns raised1
Failure to escalate calls for divisional Inspector review
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
Revise and implement the FWIN Escalation Policy using threat, risk and harm assessments and the National Decision Model.
Stated by Greater Manchester Police
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Concerns raised1
Failure to ensure staff knowledge and adherence to IBleep escalation guidelines
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.1
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Action
Update and approve the iBleep escalation procedure to specify escalation by staff placing calls and reinforce registered-nurse judgement and frequent escalation.
Stated by Stockport 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
Out-of-hours staffing arrangements, including prioritisation and access to senior clinicians, were considered adequate for urgent reviews and emergencies.
Stated by Stockport NHS Foundation Trust
Data last updated 7 September 2026