Recurring concern
Unreliable clinical task management and follow-through
- Reports that mention this concern
- 9
- Times this concern has been raised
- 9
- Stated actions linked to this concern
- 23
What this concern includes
Includes failures in the bounded clinical task-management process for identifying, assigning, prioritising, monitoring and confirming completion of safety-critical clinical tasks, including acting on important test results, making referrals, arranging specialist consultations and ensuring urgent tasks are followed through.
What is not included
- Excludes generic workforce shortages, workload or communication-volume concerns unless they directly cause failure of the clinical task-management and follow-through process.
- Excludes failures in the clinical judgement or quality of treatment after a task has been reliably assigned and completed.
- Excludes generic documentation or record-keeping deficiencies unless they prevent clinical tasks from being assigned, tracked or confirmed as completed.
- Excludes non-clinical operational task systems and administrative actions that are not safety-critical clinical tasks.
- Excludes isolated delays in risk assessment, referral or review where no broader failure of clinical task management or follow-through is asserted.
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.
Reports and published responses 9 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of a system for checking completion of important clinical tasks and referrals
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East Kent Hospitals University 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.5
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East Kent Hospitals University NHS Foundation Trust
Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
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East Kent Hospitals University NHS Foundation Trust
Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
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East Kent Hospitals University NHS Foundation Trust
Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
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East Kent Hospitals University NHS Foundation Trust
Prepare a business case and assess internal resources for funding a dedicated Cardiology MDT Coordinator role.
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East Kent Hospitals University NHS Foundation Trust
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
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Concerns raised1
Failure to complete allocated clinical tasks within the responsible shift
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East London 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.3
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East London NHS Foundation Trust
Train qualified nursing staff in nurse-in-charge responsibilities, including allocation and monitoring of outstanding tasks.
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East London NHS Foundation Trust
Develop a longer electronic training package for the nurse-in-charge role.
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East London NHS Foundation Trust
Use a standardised handover template to identify and allocate outstanding nursing and medical tasks, with senior nursing oversight.
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Concerns raised1
Failure to record clinical task communications on the medical records system
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Ashton Medical Centre
- NHS Greater Manchester Integrated Care Board
- SSP Health
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
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Ashton Medical Centre and SSP Health
Reinforce use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
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NHS Greater Manchester Integrated Care Board
Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
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NHS Greater Manchester Integrated Care Board
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
-
NHS Greater Manchester Integrated Care Board
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
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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Ashton Medical Centre and SSP Health
The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
-
Concerns raised1
Failure of doctors to prioritise work by reviewing the task book for urgent tasks
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East Lancashire Hospitals NHS 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.4
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East Lancashire Hospitals NHS Trust
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
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East Lancashire Hospitals NHS Trust
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
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East Lancashire Hospitals NHS Trust
Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.
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East Lancashire Hospitals NHS Trust
Update SOP046 to require medical and nursing staff to verify completion of doctors’ tasks before leaving the ward.
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Concerns raised1
Lack of clear clinical ownership of specialist consultation actions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- Tameside and Glossop Integrated 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
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Tameside and Glossop Integrated Care NHS Foundation Trust
Amend the Critical Care Unit daily review chart to document clearly who referred patients to the Liver Unit and when.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS England
The concerns fall under the Trust’s remit rather than NHS England’s functions.
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NHS England
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
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Concerns raised1
Absence of an audit system for timely referrals
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring 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 distinguish clinical assessment tasks from true administration tasks
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Solihull Clinical Commissioning Group
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
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NHS Solihull Clinical Commissioning Group
Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.
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Concerns raised1
Lack of clear ownership and responsibility for referrals to secondary care
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- G4S Forensic & Medical Services (UK) Ltd
- Premier Physical Healthcare
- Spectrum Community Health C.I.C.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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G4S Forensic & Medical Services (UK) Ltd
Require urgent secondary-care referrals to be discussed with the senior administrator and senior nurse.
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G4S Forensic & Medical Services (UK) Ltd
Inform the current GP provider of requirements for secondary-care referrals under the new contract.
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Premier Physical Healthcare
Introduce podiatry procedures requiring SystmOne communication and urgent tasking for necessary secondary-care referrals.
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Spectrum Community Health C.I.C.
Issue referral guidance requiring the referring doctor to complete and monitor referrals, retain responsibility, and avoid delegating urgent referrals.
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Spectrum Community Health C.I.C.
Circulate and discuss GMC guidance on delegation and referral through continuing professional development.
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Concerns raised1
Failure to follow specialist advice
Linked response
- University Hospitals Birmingham NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University Hospitals Birmingham NHS Foundation Trust
Radiologists need not automatically follow specialist requests because they independently assess clinical need, likely benefit and potential intervention.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026