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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Care Quality Commission6
Department of Health and Social Care3
Stockport NHS Foundation Trust3
Cwm Taf Morgannwg University Local Health Board2
ADS (Addiction Dependency Solutions)1
Anson Court Residential Home1
Bamford Grange Care Home1
Bedfordshire Hospitals NHS Foundation Trust1
Belong Limited1
Berkshire and Surrey Pathology Services1
Borough Care Ltd1
Calderdale Borough Council1
Cann House Care Home1
Caremark (Chiltern & Three Rivers)1
Central and North West London NHS Foundation Trust1
NHS trust10
Health and social care service regulator6
Healthcare site4
Nursing home4
Ministerial department3
Domiciliary care provider2
Health-system partnership2
Local health board2
Nursing-home operator2
Private limited company2
Registered charity2
Company1
English county council1
English metropolitan district council1
English unitary authority1
Reports and published responses 35 reports
See individual reports that have raised this concern, and the actions taken in response
South Wales Central
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.
Linked response
Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Cwm Taf Morgannwg University Local Health Board
Implement and operate an escalation policy enabling midwives to contact the on-call Obstetric Consultant and Senior Midwife directly.
Berkshire
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.
Linked response
Independent Healthcare Providers Network
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Independent Healthcare Providers Network
Continue a CQC learning programme to understand outstanding safety practice and support its adoption across independent healthcare providers.
Independent Healthcare Providers Network
Discuss escalation policies in independent acute hospitals with the CQC.
Independent Healthcare Providers Network
Conduct a scoping exercise on providers’ assurance of staff awareness of NEWS and sepsis training.
Independent Healthcare Providers Network
Encourage providers to establish formal service-level agreements with neighbouring providers for higher-acuity care transfers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Independent Healthcare Providers Network
Patient transfer does not indicate inappropriate originating care or admission, and independent hospitals can safely manage unanticipated deterioration through planned transfer arrangements.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Independent Healthcare Providers Network
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.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Independent Healthcare Providers Network
Independent hospitals already have clear processes to manage deterioration and arrange transfers to higher-acuity settings when necessary.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
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.
Linked response
Pennine Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Pennine Care NHS Foundation Trust
Develop and implement a Stockport escalation process and protocol for rejected referrals and disagreements about psychiatric assessment.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Pennine Care NHS Foundation Trust
Evidence showed RAID planned and made a psychiatric referral, although the outpatient referral was not accepted.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
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.
Linked response
Addiction Dependency Solutions
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Addiction Dependency Solutions
Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.
Manchester South
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.
Linked response
Stockport NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Stockport NHS Foundation Trust
Develop an implementation plan for rolling out the National Early Warning System independently of the delayed electronic patient record launch.
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
University Hospitals Sussex NHS Foundation Trust
Introduce a revised NEWS policy allowing contact with the staff member best placed to provide timely assistance.
Manchester West
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.
Linked responses
Belong
Care Quality Commission
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Care Quality Commission
Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.
Belong
Remind Support Workers how to escalate health concerns and seek external professional advice through staff training, induction, supervision, reviews and audits.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Care Quality Commission
The provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Care Quality Commission
Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.
No action considered necessaryThe respondent said that no further action was needed.
Manchester South
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.
Linked response
Greater Manchester Police
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Greater Manchester Police
Revise and implement the FWIN Escalation Policy using threat, risk and harm assessments and the National Decision Model.
Manchester South
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.
Linked response
Stockport NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Stockport NHS Foundation Trust
Update and approve the iBleep escalation procedure to specify escalation by staff placing calls and reinforce registered-nurse judgement and frequent escalation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Stockport NHS Foundation Trust
Out-of-hours staffing arrangements, including prioritisation and access to senior clinicians, were considered adequate for urgent reviews and emergencies.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.