Recurring concern
Failure to escalate patient-safety concerns to senior oversight
- Reports that mention this concern
- 14
- Times this concern has been raised
- 15
- Stated actions linked to this concern
- 20
What this concern includes
Includes failures by clinical, care or operational staff and teams to recognise, report or escalate patient-safety concerns, significant care problems or serious safety matters promptly through the appropriate senior-staff or senior-management pathway.
What is not included
- Excludes failures to act after a safety concern has already been escalated; those concern senior oversight response rather than upward escalation.
- Excludes escalation processes for non-safety matters, routine administrative issues or ordinary performance concerns.
- Excludes escalation within a separately named safety system or pathway when that system provides the more specific supported boundary.
- Excludes failures involving escalation of a clinical deterioration episode where the concern is solely obtaining immediate clinical treatment rather than reporting the underlying safety concern to senior oversight.
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 14 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Torbay and South Devon NHS Foundation 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.5
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Torbay and South Devon NHS Foundation Trust
Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.
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Torbay and South Devon NHS Foundation Trust
Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.
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Torbay and South Devon NHS Foundation Trust
Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.
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Torbay and South Devon NHS Foundation Trust
Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.
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Torbay and South Devon NHS Foundation Trust
Commence quarterly learning events with incident reporting as a core topic.
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Concerns raised1
Failure to report omissions in important documentation to a senior colleague
This report raised 5 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 to bring issues of concern to the attention of hospital authorities
This report raised 6 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 to identify and escalate observation suspension in the 72-hour report
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- North East London NHS Foundation 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
-
North East London NHS Foundation Trust
Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Concerns about care provision and coordination are mainly for the NHS Trust to address.
-
Concerns raised1
Failure to escalate operational problems to the on-call manager
This report raised 7 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 to escalate recurring unsafe clinical waste disposal to senior managers
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Care Quality Commission
Existing glove-disposal policies, staff awareness, safety checks, and the new PPE policy and checking system were considered sufficient responses.
-
Department of Health and Social Care
Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.
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Concerns raised1
Failure to directly inform senior clinical staff of disclosed suicide risk
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Devon University Healthcare NHS Foundation 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.3
-
Royal Devon University Healthcare NHS Foundation Trust
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
-
Royal Devon University Healthcare NHS Foundation Trust
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
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Royal Devon University Healthcare NHS Foundation Trust
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Royal Devon University Healthcare NHS Foundation Trust
Existing training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
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Royal Devon University Healthcare NHS Foundation Trust
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
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Concerns raised1
Lack of timely escalation of serious ED/ABD safety matters to senior management
This report raised 16 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 junior staff to identify deterioration and escalate to senior staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Birmingham NHS Foundation 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.2
-
University Hospitals Birmingham NHS Foundation Trust
Increase weekend consultant availability and establish gastroenterology consultant ward rounds at Good Hope Hospital.
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University Hospitals Birmingham NHS Foundation Trust
Improve communication with senior medical staff so emergent complications are escalated regardless of time or day.
-
Concerns raised1
Failure to escalate welfare incidents to the on-call senior manager
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS Greater Manchester Integrated Care Board
- Pennine Care NHS Foundation 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
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NHS Greater Manchester Integrated Care Board
Develop a pan-Greater Manchester response protocol defining roles, responsibilities, shared risk assessment, communication and escalation arrangements.
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NHS Greater Manchester Integrated Care Board
Establish the Greater Manchester Responding to Crisis Board to oversee cascading, embedding and delivery of the response protocols.
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NHS Greater Manchester Integrated Care Board
Embed the response protocols within partner agencies and cascade them across their workforces through the Responding to Crisis Board.
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Pennine Care NHS Foundation Trust
Issue a memo to all staff increasing awareness of the requirement to seek support from on-call managers.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026