Recurring concern
Failure to provide timely medical review of admitted patients
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Request correctionFirst reported 4 Oct 2013•Latest report 17 Jun 2025
What this concern includes
Includes failures of the inpatient medical-review process involving absent, delayed or insufficiently timely review of admitted or transferred patients, including review prompted by clinical observations, deterioration, presenting symptoms or a request from ward staff.
Not included
- Excludes delays limited to consultant review where the broader medical-review process is not deficient.
- Excludes nursing observations, monitoring or escalation failures when no failure to provide medical review is identified.
- Excludes generic staffing, documentation, communication or handover deficiencies unless they directly result in absent or delayed medical review of an admitted patient.
- Excludes outpatient, community or non-inpatient clinical reviews.
- Reports
- 24
- Individual concerns
- 27
- Date range
- 2013–2025
- Stated actions
- 35
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
Delays in medical review following an inpatient fall
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.
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
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Action
Expand resident-doctor induction content on responding to deteriorating patients and prioritise overnight reviews for clinically deteriorating patients.
Stated by the Rotherham NHS Foundation Trust -
Action
Move towards employing two medical registrars on call overnight.
Stated by the Rotherham NHS Foundation Trust -
Action
Review national inpatient-falls audit data and share findings and improvement actions for qualifying injured inpatients.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Delays in medical review due to doctor staffing levels
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.2
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Action
Implement changes and processes to ensure patients are properly informed of their imaging results.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Establish a hospital out-of-hours service in the surgical department to provide a more robust response and senior support to surgical wards.
Stated by Mid and South Essex NHS Foundation Trust
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
NEWS2 escalation, trigger response, out-of-hours support and consultant acting-down arrangements provide sufficient staffing safeguards for urgent surgical cases.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Failure to ensure specialist bariatric team review of post-operative gastric bypass patients
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.3
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Action
Implement a Bariatric Discharge Protocol in the pathway booklet requiring pre-discharge specialist review, pain-control assessment, discharge criteria and consultant discussion when criteria are unmet.
Stated by Portsmouth Hospitals University NHS Trust -
Action
Disseminate the Bariatric Discharge Protocol through surgical governance and team meetings and email it to surgical staff with bariatric out-of-hours or emergency responsibility.
Stated by Portsmouth Hospitals University NHS Trust -
Action
Further disseminate the Bariatric Discharge Protocol at the Biannual AGM, nursing surgical study day and surgical ward-level safety huddles.
Stated by Portsmouth Hospitals University NHS Trust
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Concerns raised1
Delays in clinical review and referral for suspected infection after rehabilitation-hospital arrival
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 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 to escalate clinically significant melaena for timely medical review
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
Provide deteriorating-patient recognition and management training to ward nurses through the Critical Care Outreach Team.
Stated by Whittington Health NHS Trust -
Action
Introduce ward-nurse training on recognising and escalating gastrointestinal bleeding, led by the endoscopy nursing team.
Stated by Whittington Health NHS Trust
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Concerns raised1
Failure to ensure timely medical review after deterioration and repeated requests
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.
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Concerns raised1
Failure to provide senior clinician review after admission
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 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
Escalate cases without an enacted management plan to the Nurse in Charge or senior decision-maker and record the escalation in nursing documentation and Datix.
Stated by University Hospitals of North Midlands NHS Trust
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 absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised1
Failure to require obstetrician review on admission with reduced fetal movement and delayed induction of labour
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 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 raised2
Failure to review patients and escalate care when EWS trigger points require it
Failure of registrars to review patients during ward visits
This report raised 11 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
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Implemented NEWS2, including revised observation and escalation processes and associated staff training.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Develop a triggered referral process to orthogeriatricians for patients requiring senior review.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Review and revise consultant job plans to support consultant ward-round availability, subject to management approval.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Conduct a case-note review of orthopaedic wards covering daily documentation, reviewing doctor grade and indicated orthogeriatric review.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to provide medical review after ward rounds
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026