First reported 3 Jan 2014•Latest report 8 Jun 2026
Definition
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
Distinct published reports
Individual concerns
42
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
54
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.
Department of Health and Social Care9
NHS England5
Essex Partnership University NHS Foundation Trust4
Care Quality Commission3
National Institute for Health and Care Excellence2
NHS North East and North Cumbria Integrated Care Board2
Royal College of Surgeons of England2
South Tyneside and Sunderland NHS Foundation Trust2
the Newcastle Upon Tyne Hospitals NHS Foundation Trust2
49 Marine Avenue Surgery1
Academy of Medical Royal Colleges1
Association Of Anaesthetists (Great Britain & Ireland)1
Avon and Wiltshire Mental Health Partnership NHS Trust1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
NHS trust26
Ministerial department9
Integrated care board7
Executive non-departmental public body6
Healthcare site6
Independent healthcare provider5
Health and social care service regulator3
Health professional body3
Multi-service care provider3
Type not available2
Clinical commissioning group1
Community interest company1
Company1
Company limited by guarantee1
English unitary authority1
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.
South Yorkshire (West)
Concerns raised1
Lack of clear allocation and recording of responsibility for ongoing patient follow-up and 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 concerns
Each 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
Position
Existing electronic records identify the admitting Consultant responsible for patient care and follow-up until responsibility is formally transferred.
Stated by the Rotherham NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Coventry
Concerns raised1
Unclear and misaligned overall clinical responsibility for patients with ruptured aneurysms
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 concerns
Each 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
Action
Work with partner organisations to advocate for sustainable workforce planning, clearer clinical governance, and equitable access to specialist interventional services.
Stated by Royal College of RadiologistsStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Develop and update professional guidance and standards supporting timely care and clarifying roles and responsibilities in complex multidisciplinary pathways.
Stated by Royal College of RadiologistsStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Develop a position statement with SBNS and BNVG recommending how clinical care for subarachnoid haemorrhage patients should be managed.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Neurosurgeons and linked multidisciplinary teams are best placed to manage subarachnoid haemorrhage patients and determine treatment.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing pathways should remain unchanged, with patients unsuitable for coiling remaining under neurosurgical care.
Stated by Royal College of PhysiciansExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NHS providers, commissioners and national bodies are responsible for organising, resourcing and operationally delivering emergency and specialist services.
Stated by Royal College of RadiologistsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The RCR cannot mandate service reconfiguration or staffing levels, limiting its ability to implement those changes directly.
Stated by Royal College of RadiologistsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Local multidisciplinary teams may determine how SAH services are delivered, provided neurosurgical and interventional neuroradiology expertise is included.
Stated by Royal College of Surgeons of EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Neurosurgeons are considered best placed to manage SAH patients across pre-treatment, treatment and post-treatment care.
Stated by Royal College of Surgeons of EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Absence of clear responsibility for explaining NG tube necessity
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 concerns
Each 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
Action
Provide consent guidance on supported decision-making, informed consent, treatment options, material risks and patient-specific communication.
Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 10 October 2025.
Action
Update consent guidance to reflect revised Good Surgical Practice.
Stated by Royal College of Surgeons of EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 October 2025.
Action
Consult the Royal College of Anaesthetists on coordinated advice for complex anaesthetic consent and risk communication.
Stated by Royal College of Surgeons of EnglandStated plannedThe respondent said that this action was planned when they made their response on 10 October 2025.
West Sussex, Brighton and Hove
Concerns raised2
Lack of multidisciplinary assessment and senior consultant oversight of community urology patients
Failure of senior clinicians to retain responsibility for patients throughout private hospital care
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 concerns
Each 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
Action
Require consultants to retain responsibility for patients throughout their clinical pathway under the Practising Privileges policy.
Stated by Circle Health Group and Goring Hall HospitalStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Implement a Care of the Deteriorating Patient policy defining consultant and Resident Medical Officer responsibilities and requiring escalation when consultants fail to respond appropriately.
Stated by Circle Health Group and Goring Hall HospitalStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing policies sufficiently establish consultants’ continuing responsibility for patients and define RMO and consultant responsibilities during deterioration.
Stated by Circle Health Group and Goring Hall HospitalExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
CHG considers its consultant-responsibility policies clear and effective, requiring no revision or further action at this time.
Stated by Circle Health Group and Goring Hall HospitalNo action considered necessaryThe respondent said that no further action was needed.
Position
Failures by individual clinicians fall outside prosecutorial remit because prosecutorial powers extend only to registered providers or registered managers.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Surrey
Concerns raised1
Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
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 concerns
Each 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
Action
Implement and disseminate the Emergency Medicine–Medical–Psychiatry Joint Care Guideline clarifying clinical responsibilities and escalation.
Stated by Epsom and St Helier University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clinical matters fall outside the commissioning organisation’s remit.
Stated by NHS Southwest London Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Clinical matters are the responsibility of the relevant Trusts.
Stated by NHS Southwest London Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Lack of clear responsibility for care of patients during illness
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 concerns
Each 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
Action
Maintain established pathways for circumstances in which a receiving provider passes a referral back to NWAS.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2025.
Action
Implement an overnight process for breached response times, including welfare calls and priority clinical escalation where deterioration is suspected.
Stated by Cumbria Health LimitedStated completedThe respondent said that this action was complete when they made their response on 15 July 2025.
Action
Continue discussions with the ICB, practices and primary-care representatives on formal arrangements for safely handing cases between daytime and out-of-hours services.
Stated by Cumbria Health LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2025.
Action
Introduce outcomes-based funding, integrated digital records and personalised care plans.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 15 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Wider risks from fragmented responsibility across NHS services should be addressed by national stakeholders through national guidance and structural changes.
Stated by Carlisle Central PracticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Contractual arrangements with partner organisations are considered sufficient to ensure continuity after NWAS transfers care.
Stated by North West Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Once a referral is accepted, responsibility for the patient's care rests with the receiving provider rather than NWAS.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Northumberland
Concerns raised1
Lack of clear accountable oversight of outpatient care
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 concerns
Each 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
Action
Review internal referral processes to clarify responsibilities and improve timely specialist referrals.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Develop and implement eating-disorder management and under-18 safe-management policies covering weight-loss presentations.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Implement Dietetics management restructuring with a Community Team Lead overseeing outpatient capacity, reporting, monitoring, planning and escalation support.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Establish a Nutrition MDT with Gastroenterology and mental-health input for complex and vulnerable Dietetic outpatients.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Overall and specialty-specific outpatient care responsibilities rest with GPs, dieticians, named consultants and care teams, with escalation as needed.
Stated by NHS North East and North Cumbria Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised1
Failure to establish clear 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 concerns
Each 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
Action
Continue collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing cross-organisational clinical collaboration generally provides sufficient coordination, with shared care used where specifically requested.
Stated by Somerset NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Failure to ensure overall consultant responsibility for patients receiving care from multiple teams
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 concerns
Each 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
Action
Share, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2024.
Essex
Concerns raised1
Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
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 concerns
Each 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
Position
The Code of Practice does not require a Responsible Clinician for patients held under section 5(2), and the Trust complied with applicable provisions.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
