Recurring concern
Failure to maintain clear clinical responsibility for patient care
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Request correctionFirst reported 3 Jan 2014•Latest report 8 Jun 2026
What this concern includes
Includes failures of an explicitly clinical care responsibility arrangement in which clinicians or senior clinical staff do not retain, clearly assign or actively oversee responsibility for patient care, including during private hospital stays, community care and post-discharge care.
Not included
- Excludes generic delegation or supervision failures not tied to responsibility for the patient’s overall clinical care.
- Excludes administrative, incident-investigation or governance responsibility failures that do not concern ongoing clinical responsibility for patient care.
- Excludes individual delays, omissions or treatment failures unless they arise from the failure to retain or clearly assign clinical responsibility.
- Reports
- 39
- Individual concerns
- 42
- Date range
- 2014–2026
- Stated actions
- 54
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 identified consultant oversight of diabetic and gynaecological aspects of high-risk pregnancy 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.
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 communication between hospital departments about responsibility for patient 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.3
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Action
Agree the renal admission pathway with advice clarifying the reason for referral.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Amend Trust Internal Professional Standards to reduce failures caused by misunderstanding between departments.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Escalate and document patients requiring specialty care through Emergency Department huddles and the Huddle Log.
Stated by University Hospitals of North Midlands 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
The absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised1
Failure to assign clear responsibility for discharge decision making
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.1
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Action
Implement a CDU standard operating procedure defining responsibility across the patient pathway.
Stated by Doncaster and Bassetlaw Teaching Hospitals 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
A CDU consultant made the discharge decision and identified the patient as medically fit for discharge, subject to specified conditions.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to assign overall responsibility for asthma care
This report raised 23 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
Share examples of effective asthma-service practice through the clinical networks.
Stated by NHS England
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Concerns raised1
Failure to establish clear responsibility for PEG feeding assessment and key decisions
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
Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.
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.3
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Position
CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Stated by Care Quality Commission
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Position
CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.
Stated by Care Quality Commission -
Position
The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to assign clear responsibility for coordinating and delivering care before discharge
This report raised 7 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 assign overall management responsibility for care
This report raised 24 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
Unclear post-procedure clinical accountability
This report raised 7 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 clear allocation of a named keyworker or lead nurse for community care coordination
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.
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 assign clinical leadership and psychiatric monitoring during interim care pending Mental Health Act assessment
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.2
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Action
Specify the Home Treatment Team’s expected risk-management role in referrals made while clients await Mental Health Act assessment.
Stated by Oxleas NHS Foundation Trust -
Action
Hold thrice-weekly zoning meetings for high-risk individuals and minute agreed risk-mitigation actions.
Stated by Oxleas NHS Foundation Trust
Data last updated 7 September 2026