First reported 6 Jun 2014•Latest report 11 Nov 2025
Definition
What this concern includes
Includes failures of the bounded care-team liaison and clinical-overview process, including inadequate communication between nursing and medical staff, incomplete sharing or review of patient concerns and attendances, and failures to maintain a longitudinal view across different staff or visits when these can cause deterioration or significant symptoms to be missed.
Not included
Excludes generic communication, staffing, training or documentation deficiencies unless they directly impair the shared clinical overview of a patient's changing concerns.
Excludes failures confined to a named handover, discharge, referral or inter-agency information-sharing system where that distinct process is the unsafe condition.
Excludes failures involving only an individual clinician's diagnostic judgment or clinical treatment when no shared-overview or liaison deficiency is identified.
Excludes neutral descriptions of multidisciplinary working or care coordination without an unsafe failure to maintain a current clinical overview.
Reports
9
Distinct published reports
Individual concerns
11
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
20
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 Care2
Blackpool Teaching Hospitals NHS Foundation Trust1
Bolton NHS Foundation Trust1
Care Quality Commission1
East of England Community Health and Care NHS Trust1
Haughton Thornley Medical Centres1
King'S College Hospital NHS Foundation Trust1
NHS Cumbria Clinical Commissioning Group1
NHS England1
NHS Greater Manchester Integrated Care Board1
North Cumbria Integrated Care NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Roseland1
Tameside General Hospital1
NHS trust6
Healthcare site2
Ministerial department2
Clinical commissioning group1
Executive non-departmental public body1
Health and social care service regulator1
Integrated care board1
Residential care home1
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.
Inner South London
Concerns raised1
Failure to maintain continuity of care across admitting teams
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
Produce and use the Problem List Etiquette Guide to standardize problem-list and associated documentation practices.
Stated by King'S College Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Establish a cross-Trust EPIC Documentation Quality Group to assess data quality, oversee documentation enhancements and lead targeted quality-improvement initiatives.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2025.
Action
Agree EPIC documentation metrics and audit standards to establish baseline quality and track improvement.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Action
Oversee EPIC build changes, including navigators and note templates, to facilitate documentation quality improvement.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Action
Design and oversee targeted documentation quality-improvement projects before wider rollout.
Stated by King'S College Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Manchester South
Concerns raised1
Insufficient sharing of information about feeding and weight loss concerns
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.1
Action
Digitalise the red book and progressively add information and functionality to improve access to growth and feeding data.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2025.
Norfolk
Concerns raised1
Failure to maintain and review a complete view of a patient's presentation and deterioration across community visits
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 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
Pilot named-clinician and geographical-area caseloads and analyse the results to inform the future community nursing model.
Stated by East of England Community Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2024.
Action
Develop more consistent approaches to patient-record review before visits, including for urgent-care visits.
Stated by East of England Community Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Operational pressures make consistent allocation of individual community clinicians difficult, requiring staff movement to minimise patient risk.
Stated by East of England Community Health and Care NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Clinicians attending urgent care visits may be unable to review patient records before the visit, limiting consistent record review.
Stated by East of England Community Health and Care NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Lack of liaison and overview across care staff
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 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.
Manchester South
Concerns raised1
Failure to communicate deterioration between ward doctors and nursing staff
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
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Blackpool and the Fylde
Concerns raised1
Failure to incorporate identified clinical findings into subsequent nursing care plans
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.1
Action
Implement lessons learned from the internal review of patient care.
Stated by Blackpool Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Manchester West
Concerns raised3
Failure to record family concerns, clinical attendances and observed symptoms in patient notes
Inadequate training of nursing and medical staff in the above information-management processes
Failure of nursing and medical staff to liaise about patient concerns and clinical attendances
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.7
Action
Provide Darley Court staff direct access to an out-of-hours GP and require consultation details to be documented in Darley Court medical notes.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2015.
Action
Disseminate record-keeping guidance and escalation guidance, and remind staff to document and escalate patient concerns appropriately.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2015.
Action
Provide weekly and monthly documentation and record-keeping training for Darley Court staff.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2015.
Action
Conduct monthly documentation audits to monitor compliance and improve record-keeping quality.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2015.
Action
Recruit and place a permanent full-time doctor at Darley Court Intermediate Care.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2015.
Action
Increase consultant attendance sessions at Darley Court Intermediate Care beyond the existing two sessions per week.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 30 December 2015.
Action
Include the doctor and a senior therapy-team member in the daily morning safety huddle.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 30 December 2015.
Manchester South
Concerns raised1
Failure to ascertain clinically significant chest symptoms from care staff
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
Undertake personal reading, continuing professional development, and information gathering on thoracic trauma.
Stated by Haughton Thornley Medical CentresStatus unclearThe respondent did not make the status of this action clear when they made their response on 25 November 2015.
Action
Ensure all practice GPs undertake thoracic-trauma reading and attend relevant education.
Stated by Haughton Thornley Medical CentresStated plannedThe respondent said that this action was planned when they made their response on 25 November 2015.
Action
Present and discuss the incident at the relevant educational meeting to identify further changes.
Stated by Haughton Thornley Medical CentresStated plannedThe respondent said that this action was planned when they made their response on 25 November 2015.
South and East Cumbria
Concerns raised1
Failure to maintain an overall view of escalating patient risk
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Cumbria Partnership NHS Foundation Trust is responsible for addressing the four concerns relating to events on the Dova Unit.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of the bounded care-team liaison and clinical-overview process, including inadequate communication between nursing and medical staff, incomplete sharing or review of patient concerns and attendances, and failures to maintain a longitudinal view across different staff or visits when these can cause deterioration or significant symptoms to be missed.
