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 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.
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
Assign every acute admissions patient a named nurse and communicate nurse responsibility to patients, carers and staff each shift.
Stated by Barts Health NHS Trust
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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.
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 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 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.
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
Write a multi-agency protocol defining shared health and social care responsibility during mental health assessments, including when resources are unavailable.
Stated by Approved Mental Health Professional/Social Work Service -
Action
Roll out the multi-agency protocol through monthly manager meetings and cascading it to health and social care teams.
Stated by Approved Mental Health Professional/Social Work Service -
Action
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.
Stated by Approved Mental Health Professional/Social Work Service
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Action
Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.
Stated by Approved Mental Health Professional/Social Work Service
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 local authority is responsible for arranging an Approved Mental Health Professional assessment when the referral is not made to Trust services.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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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.
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 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.
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
Implement a psychiatric protocol requiring documented risk assessments, action on identified risks, communication with relevant healthcare professionals, and periodic review.
Stated by Green Surgery Ltd -
Action
Follow up medication non-compliance reports by inviting patients to appointments, discussing non-compliance impacts, and reassessing resulting risks.
Stated by Green Surgery Ltd
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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.
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 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.
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
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
Stated by Partnerships in Care Group Limited
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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.
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.
Data last updated 7 September 2026