Recurring concern
Failure to maintain clear clinical responsibility for patient care
- Reports that mention this concern
- 39
- Times this concern has been raised
- 42
- Stated actions linked to this concern
- 54
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.
What is 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.
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 39 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Lack of clarity about primary nursing responsibility
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health 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.1
-
Barts Health NHS Trust
Assign every acute admissions patient a named nurse and communicate nurse responsibility to patients, carers and staff each shift.
-
Concerns raised1
Failure to assign overall clinical management responsibility
This report raised 8 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.
-
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
-
G4S Forensic & Medical Services (UK) Ltd
Require urgent secondary-care referrals to be discussed with the senior administrator and senior nurse.
-
G4S Forensic & Medical Services (UK) Ltd
Inform the current GP provider of requirements for secondary-care referrals under the new contract.
-
Premier Physical Healthcare
Introduce podiatry procedures requiring SystmOne communication and urgent tasking for necessary secondary-care referrals.
-
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.
-
Spectrum Community Health C.I.C.
Circulate and discuss GMC guidance on delegation and referral through continuing professional development.
-
Concerns raised1
Failure to assign responsibility for patient care, mental health assessment and resulting treatment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Approved Mental Health Professional/Social Work Service
- Avon and Wiltshire Mental Health Partnership 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
-
Approved Mental Health Professional/Social Work Service
Write a multi-agency protocol defining shared health and social care responsibility during mental health assessments, including when resources are unavailable.
-
Approved Mental Health Professional/Social Work Service
Roll out the multi-agency protocol through monthly manager meetings and cascading it to health and social care teams.
-
Approved Mental Health Professional/Social Work Service
Discuss with AWP how responsibility is allocated between mental health assessments and Mental Health Act assessments at each stage, using urgent telephone contact when necessary.
-
Approved Mental Health Professional/Social Work Service
Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Avon and Wiltshire Mental Health Partnership NHS Trust
The local authority is responsible for arranging an Approved Mental Health Professional assessment when the referral is not made to Trust services.
-
Concerns raised1
Delays in resolving disputes over which organisation should treat a patient
This report raised 2 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.
-
Concerns raised1
Failure of clinicians to retain responsibility for patients’ safety and wellbeing in the community
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Green Surgery Ltd
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
-
Green Surgery Ltd
Implement a psychiatric protocol requiring documented risk assessments, action on identified risks, communication with relevant healthcare professionals, and periodic review.
-
Green Surgery Ltd
Follow up medication non-compliance reports by inviting patients to appointments, discussing non-compliance impacts, and reassessing resulting risks.
-
Concerns raised1
Failure to establish clear nursing responsibility for patient care
This report raised 10 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.
-
Concerns raised1
Unclear responsibility for stopping physical observations
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Partnerships in Care Group Limited
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
-
Partnerships in Care Group Limited
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
-
Concerns raised1
Failure of surgical teams to maintain ongoing oversight after discharge
This report raised 4 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026