First reported 28 Aug 2013•Latest report 17 Feb 2026
Definition
What this concern includes
Includes failures to conduct a clinically required assessment or full clinical review promptly and appropriately when the assessment is needed to identify or evaluate a patient's condition and guide safe care, including the anchor's delayed full review and delayed assessment of a patient's condition.
Not included
Excludes specialised assessment pathways with a distinct named subject or established safety concern, such as full mental-health assessments, VTE risk reviews or post-procedure complication assessments, unless the assertion also directly supports the same general clinical-assessment failure.
Excludes failures limited to the location, documentation, communication or handover of an assessment where the assessment itself was timely and appropriate.
Excludes delays in treatment, medication, escalation or referral when the required clinical assessment was completed appropriately and the remaining failure is downstream.
Excludes routine reassessment or review where no clinically required assessment or full clinical review is identified.
Reports
25
Distinct published reports
Individual concerns
28
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
38
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.
NHS England5
Care Quality Commission2
Aneurin Bevan University LHB1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Bedford Prison1
Cwm Taf Morgannwg University Local Health Board1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Family of Julia Macpherson1
Glebelands1
Greater Manchester Health and Social Care Partnership1
HCRG Care Coventry LLP1
Marine Lake Medical Practice1
Ministry of Justice1
Monkstone House1
NHS trust14
Executive non-departmental public body5
Healthcare site4
Integrated care board3
Local health board3
Type not available3
Health and social care service regulator2
Ministerial department2
Multi-service care provider2
Health-system partnership1
Limited liability partnership1
Nursing home1
Prison or young offender institution1
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.
Bedfordshire and Luton
Concerns raised1
Failure to arrange follow-up medical assessment when a prisoner's condition is not improving
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.
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
Implement a single agreed UTI protocol standardising responsibilities, observations, escalation routes and handover expectations.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Provide staff guidance on recognising UTI signs, initiating the protocol, completing observations and undertaking follow-up checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Action
Assure documentation and observations, record improvement needs, and escalate issues concerning timescales or procedures to senior leaders.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 February 2026.
Liverpool and the Wirral
Concerns raised1
Failure to ensure face-to-face clinical assessment of vulnerable elderly patients
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised2
Lack of clinical assessment before discharge home from the Emergency Department
Lack of clinical assessment before referral for mental health assessment in Emergency Department patients
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.
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
Communicate the requirement for medical review before Emergency Department referral to mental health services.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 August 2025.
Action
Audit compliance monthly with medical review before Emergency Department referral to mental health services and report results through governance.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 August 2025.
Oxfordshire
Concerns raised1
Delays and lack of direction in obtaining clinical 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 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
Administer monthly knowledge quizzes covering shared learning, procedure changes and NHS Pathways triage principles, with re-quizzing where results indicate insufficient understanding.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Action
Hold monthly end-to-end 111 case-review meetings to identify learning and implement necessary process or system changes.
Stated by South Central Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local services manage the availability of services matched to the NHS Pathways recommended outcome.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust found no inherent or recurrent problem with staff failing to seek clinical advice when appropriate.
Stated by South Central Ambulance Service NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Delays in clinical assessment resulting in patients leaving hospital before assessment
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.7
Action
Publish and implement the two-year delivery plan for recovering urgent and emergency care services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Action
Support regions and providers to eliminate longer-term crowding in emergency departments and improve patient flow.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Action
Use operational planning guidance to direct health systems toward improved patient flow and clinical outcomes.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Action
Develop and obtain approval for a Standard Operating Procedure governing patients leaving the emergency department before assessment or treatment.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Action
Disseminate the approved Standard Operating Procedure across urgent and emergency care areas.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
Action
Implement the NHSE Acuity Tool for initial assessment and routing of patients attending Salford Royal’s emergency department.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2024.
Action
Continue work to achieve the 15-minute target for secondary assessment and enable early intervention and frontloading of essential investigations.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Salford Royal Hospital Foundation Trust is the appropriate organisation to respond to the concerns raised.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised2
Delays in medical review of acute clinical deterioration
Delays in consultant review
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.2
Action
Use Nervcentre task lists to communicate outstanding patient tasks between day and night teams during clinical handover.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Action
Provide out-of-hours patient-care coordination through a dedicated Hospital at Night team.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Manchester South
Concerns raised1
Failure of Emergency Department capacity to provide timely clinical assessment
This report raised 1 other concern. 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.5
Action
Improve patient flow through hospitals to reduce emergency department delays.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Speed up hospital discharges to reduce length of stay and improve flow.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Address unwarranted performance variation in the most challenged local systems.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Implement the Long Term Workforce Plan to improve training, staff retention, workforce reform and sustainable staffing.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 July 2023.
Action
Publish national winter operational-resilience guidance addressing emergency department waits, crowding, flow and hospital length of stay.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS Trusts are responsible for ensuring appropriate staffing, senior clinical support and diagnostic provision for anticipated demand.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to provide face-to-face GP assessment when deterioration may be present
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.5
Action
Review systems for recording and prioritising consultation and home-visit requests.
Stated by North Trafford Group PracticeStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Remind reception staff to record every home-visit request in the clinical system for clinician assessment.
Stated by North Trafford Group PracticeStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Reinforce home-visit request recording requirements through reception staff orientation and training.
Stated by North Trafford Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Progress the Greater Manchester access action plan to increase general-practice capacity and appointments, expand face-to-face GP access, reduce avoidable demand, and improve healthcare inequalities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.
Action
Review the balance between remote and face-to-face consultations across Greater Manchester general practices.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing digital systems provide clinician-triaged access to telephone, video, face-to-face consultations or home visits, with alternatives for patients unable to use them.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
CQC and NHS England will make required improvements across practices that do not meet patients’ reasonable needs.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Absence of ongoing clinician input and clinical assessment during prolonged emergency call handling
This report raised 13 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised2
Failure to seek clinical assessment when staff note deterioration in residents' health
Failure to seek clinical assessment for frail residents following falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures to conduct a clinically required assessment or full clinical review promptly and appropriately when the assessment is needed to identify or evaluate a patient's condition and guide safe care, including the anchor's delayed full review and delayed assessment of a patient's condition.
