Failure to provide face-to-face clinical assessment when clinically indicated
First to latest report 10 Oct 2013 — 14 Jan 2026
Reports that mention this concern
21
Times this concern has been raised
21
Stated actions linked to this concern
24
What this concern includes
Includes failures in clinical assessment processes where face-to-face assessment is clinically indicated but is omitted, not offered, not required by policy, or replaced by remote contact without an adequate safety threshold; include the anchor and comparable primary-care or community-care assertions.
What is not included
Excludes failures limited to telephone mental health assessment, which belong to the separately named mental-health telephone-assessment concern when that is the supported boundary.
Excludes remote consultations where the report does not identify a clinically indicated need for face-to-face assessment.
Excludes failures in treatment, referral, follow-up or diagnostic testing after an adequate face-to-face assessment has occurred.
Excludes generic access, staffing or communication deficiencies unless they directly result in failure to provide clinically indicated face-to-face assessment.
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.
Department of Health and Social Care7
NHS England2
NHS Greater Manchester Integrated Care Board2
49 Marine Avenue Surgery1
Ayurvedic Professionals Association1
Belmont Health Centre1
Berkshire Healthcare NHS Foundation Trust1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
East London NHS Foundation Trust1
General Medical Council1
General Pharmaceutical Council1
Greater Manchester Health and Social Care Partnership1
Herefordshire and Worcestershire Health and Care NHS Trust1
Kent and Medway Mental Health NHS Trust1
NHS trust9
Ministerial department7
Healthcare site5
Integrated care board3
Executive non-departmental public body2
Company limited by guarantee1
English unitary authority1
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Health-system partnership1
Independent healthcare provider1
Medicines and medical devices regulator1
Multi-service care provider1
Professional body1
Reports and published responses 21 reports
See individual reports that have raised this concern, and the actions taken in response
Kent and Medway
Concerns raised1
Failure to act on family-provided information indicating heightened and escalating risk
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Kent and Medway Mental Health NHS Trust
Vita Health Group 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.4
Kent and Medway Mental Health NHS Trust
Deliver a two-day CRAM training event for Urgent Mental Health Helpline staff to improve risk recognition, risk curiosity and co-produced care and risk management planning.
Kent and Medway Mental Health NHS Trust
Introduce visual prompts at every call station and workstation directing staff to arrange Rapid Response assessment within four hours when risk is concerning.
Vita Health Group Ltd
Update the Duty Standard Operating Procedure to require same-day routine referral action and careful consideration of family members’ information.
Vita Health Group Ltd
Deliver a reflective Duty Team session sharing case learning and the resulting Standard Operating Procedure changes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Vita Health Group Ltd
An urgent referral was not indicated because reported deterioration lacked evidence of dynamic risk, risky behaviour, suicide planning or intent.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hampshire, Portsmouth Southampton
Concerns raised1
Failure of Urgent Care Centres to provide doctor examination
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North London
Concerns raised1
Failure to provide face-to-face consultations by a doctor
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
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.1
Department of Health and Social Care
NHS England is responsible for addressing the concerns about hospital admission thresholds, in-person consultations and safety-netting advice.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Northumberland
Concerns raised1
Lack of in-person dietetic assessment recording weight and clinical observations
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
49 Marine Avenue GP Surgery (NPC Surgery
Northumbria 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.5
49 Marine Avenue GP Surgery (NPC Surgery
Reinforce face-to-face contact requirements for patients with weight loss or malnutrition through team reminders and monthly meetings.
Northumbria Healthcare NHS Foundation Trust
Routinely offer face-to-face Dietetics appointments as first contact for patients referred for nutritional support or weight loss, with in-person follow-up after necessary telephone assessment.
Northumbria Healthcare NHS Foundation Trust
Cascade safety messages on accurate height and weight measurement, assessment frequency and documentation through Trust communications and policy.
Northumbria Healthcare NHS Foundation Trust
Offer home visits to higher-risk patients who cannot or will not attend an in-person Trust appointment.
Northumbria Healthcare NHS Foundation Trust
Offer face-to-face appointments to all higher-risk patients, using telephone contact only when needed for timely intervention and followed by in-person review.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Northumbria Healthcare NHS Foundation Trust
A return to face-to-face appointments as standard requires additional resources and a commissioning review, preventing immediate universal implementation.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Northumbria Healthcare NHS Foundation Trust
The service cannot guarantee that every first appointment will be face-to-face because patient choice may prevent this.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Berkshire
Concerns raised1
Reliance on telephone rather than face-to-face appointments
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Berkshire 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.2
Berkshire Healthcare NHS Foundation Trust
Deliver five-day clinical-skills training covering named-worker responsibilities, targeted interventions, relapse prevention, discharge planning, 72-hour follow-up and evidence-based care.
Berkshire Healthcare NHS Foundation Trust
Implement quarterly audits of documented rationales for remote outpatient appointments and share results at divisional safety and quality meetings.
Norfolk
Concerns raised1
Failure to ensure preoperative review by a surgeon
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Failure to carry out detailed needs assessments of very vulnerable and elderly patients face-to-face
Linked response
Milton Keynes City Council
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
Milton Keynes City Council
Conduct face-to-face assessments following adult social care referrals for care and support.
Manchester South
Concerns raised1
Failure to provide face-to-face clinical review
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Prescribing antibiotics without examining the patient
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.