Recurring concern
Unreliable clinical task management and follow-through
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Request correctionFirst reported 16 Oct 2015•Latest report 25 Jun 2026
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.
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.
- Reports
- 9
- Individual concerns
- 9
- Date range
- 2015–2026
- Stated actions
- 23
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
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.
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.5
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Action
Implement the revised Devices MDT governance documents, including referral criteria, clinical reasoning, patient involvement, escalation and action-accountability requirements.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Apply the strengthened MDT governance model, where appropriate, to other Cardiology Service MDTs.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Maintain a centralised Devices MDT action log with named responsibility, completion dates, status tracking and escalation of outstanding actions.
Stated by East Kent Hospitals University NHS Foundation Trust
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Action
Prepare a business case and assess internal resources for funding a dedicated Cardiology MDT Coordinator role.
Stated by East Kent Hospitals University NHS Foundation Trust -
Action
Review implementation of the revised abnormal-results escalation process and compliance with completion of Devices MDT actions through governance arrangements.
Stated by East Kent Hospitals University NHS Foundation Trust
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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.
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
Train qualified nursing staff in nurse-in-charge responsibilities, including allocation and monitoring of outstanding tasks.
Stated by East London NHS Foundation Trust -
Action
Develop a longer electronic training package for the nurse-in-charge role.
Stated by East London NHS Foundation Trust -
Action
Use a standardised handover template to identify and allocate outstanding nursing and medical tasks, with senior nursing oversight.
Stated by East London NHS Foundation Trust
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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.
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
Reinforce use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
Stated by Ashton Medical Centre and SSP Health -
Action
Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
Stated by NHS Greater Manchester Integrated Care Board
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Action
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
Stated by NHS Greater Manchester Integrated Care Board
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
The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
Stated by Ashton Medical Centre and SSP Health
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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.
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
Remove doctors’ task books and route non-urgent requests through Cerner, with urgent concerns verbally escalated to medical staff or the Acute Care Team.
Stated by East Lancashire Hospitals NHS Trust -
Action
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
Stated by East Lancashire Hospitals NHS Trust -
Action
Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.
Stated by East Lancashire Hospitals NHS Trust
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Action
Update SOP046 to require medical and nursing staff to verify completion of doctors’ tasks before leaving the ward.
Stated by East Lancashire Hospitals NHS Trust
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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.
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
Amend the Critical Care Unit daily review chart to document clearly who referred patients to the Liver Unit and when.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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 concerns fall under the Trust’s remit rather than NHS England’s functions.
Stated by NHS England
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Position
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Stated by NHS England
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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.
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 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.
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
Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.
Stated by NHS Solihull Clinical Commissioning Group
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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.
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.5
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Action
Require urgent secondary-care referrals to be discussed with the senior administrator and senior nurse.
Stated by G4S Forensic & Medical Services (UK) Ltd -
Action
Inform the current GP provider of requirements for secondary-care referrals under the new contract.
Stated by G4S Forensic & Medical Services (UK) Ltd -
Action
Introduce podiatry procedures requiring SystmOne communication and urgent tasking for necessary secondary-care referrals.
Stated by Premier Physical Healthcare
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Action
Issue referral guidance requiring the referring doctor to complete and monitor referrals, retain responsibility, and avoid delegating urgent referrals.
Stated by Spectrum Community Health C.I.C. -
Action
Circulate and discuss GMC guidance on delegation and referral through continuing professional development.
Stated by Spectrum Community Health C.I.C.
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Concerns raised1
Failure to follow specialist advice
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Radiologists need not automatically follow specialist requests because they independently assess clinical need, likely benefit and potential intervention.
Stated by University Hospitals Birmingham NHS Foundation Trust
Data last updated 7 September 2026