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 escalate non-compliance with the sepsis policy
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.
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 monthly internal spot-check audits of sepsis pathway compliance and report non-compliance through incident forms.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Run a Trust-wide incident-reporting programme addressing incident and near-miss identification, reporting, learning and action.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Inadequate escalation procedures for care staff
This report raised 10 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
Lack of clarity among care staff about escalation requirements for acutely unwell patients or residents
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 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
Lack of a defined escalation process for refusal of medication and fluids
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
Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Stated by Care Quality Commission
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
Existing arrangements requiring contact with the GP provide the escalation route when care-home patients refuse medication or fluids.
Stated by NHS Greater Manchester Integrated Care Board
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Position
When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
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.1
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Action
Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.
Stated by Hampshire County Council
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Concerns raised1
Absence of a policy or procedure for escalating concerns about patient condition and delayed admission
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 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
Design an agreed escalation process for crews when emergency department staff do not act on their clinical concerns.
Stated by Welsh Ambulance Services NHS 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
Health Boards are responsible for patients in Emergency Departments or ambulances held on hospital forecourts, including addressing escalated clinical concerns.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Lack of an escalation pathway following sequential falls
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.1
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Action
Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.
Stated by Borough Care Ltd
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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 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.3
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Action
Deliver direct NEWS2 training to nursing staff, including escalation based on clinical judgement as well as numerical scoring.
Stated by The Trust -
Action
Provide tools and mechanisms for identifying deteriorating patients and clarify escalation routes using clinical experience alongside numerical scoring.
Stated by The Trust -
Action
Use trust-wide clinical updates, shared-learning sessions and safety bulletins to reinforce deterioration recognition and escalation.
Stated by The Trust
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Concerns raised1
Failure to use the escalation policy
This report raised 9 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.3
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Action
Deliver mandatory training on communication, record keeping, documentation and escalation, with compliance monitoring.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Implement an escalation policy, incident-reporting process and senior-midwife out-of-hours escalation rota.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Implement the Birthrate Plus labour-ward acuity system and support staff to use it for timely escalation.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Lack of clear escalation instructions for worsening open wounds
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.7
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Action
Apply the Lower Limb and Leg Ulcer Management Policy to standardize wound management and escalation across the Trust.
Stated by Central and North West London NHS Foundation Trust -
Action
Reinforce the wound policy, escalation responsibilities, emergency-services role, qualified-nurse attendance, reassessment, and risk-factor management with the involved team.
Stated by Central and North West London NHS Foundation Trust -
Action
Hold a follow-up meeting to assess embedded learning and systematic identification of deteriorating patients at handovers.
Stated by Central and North West London NHS Foundation Trust
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Action
Oversee reassessment of wound-care competence for all relevant staff.
Stated by Central and North West London NHS Foundation Trust -
Action
Cascade a Trust-wide clinical message reminding community nursing teams about wound policy, consent, capacity, and escalation requirements.
Stated by Central and North West London NHS Foundation Trust -
Action
Share case learning through the clinical-message process, a learning event, and the Pressure Ulcer Board.
Stated by Central and North West London NHS Foundation Trust -
Action
Retrain team members to use the NEWS2 tool for identifying deterioration and seeking emergency help.
Stated by Central and North West London NHS Foundation Trust
Data last updated 7 September 2026