Failure to reassess treatment options when clinically indicated
First to latest report 30 Jul 2014 — 25 Jun 2026
Reports that mention this concern
7
Times this concern has been raised
8
Stated actions linked to this concern
6
What this concern includes
Includes failures to review, reconsider, escalate or revise treatment options when treatment is significantly delayed, the patient's condition changes, or other clinically relevant circumstances indicate that the existing plan should be reassessed.
What is not included
Excludes generic delays in treatment where no failure to reassess or escalate treatment options is identified.
Excludes failures limited to informed-consent discussions, documentation or communication where treatment options were otherwise appropriately reviewed.
Excludes failures concerning diagnosis, referral or treatment delivery when no deficient reconsideration or escalation of treatment options is asserted.
Excludes reassessment processes governed by a separately named clinical condition or treatment pathway when that named concern provides the more specific supported boundary.
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 Care2
NHS England2
Barking, Havering and Redbridge University Hospitals NHS Trust1
Care Quality Commission1
Foxhayes Surgery GP Practice1
Herefordshire and Worcestershire Health and Care NHS Trust1
Local Care Direct Limited1
Princess Alexandra Hospital1
Queen Victoria Hospital NHS Foundation Trust1
The Foxhayes Surgery GP Practice1
NHS trust3
Executive non-departmental public body2
Ministerial department2
Health and social care service regulator1
Healthcare site1
Independent healthcare provider1
Type not available1
Reports and published responses 7 reports
See individual reports that have raised this concern, and the actions taken in response
Devon, Plymouth and Torbay
Concerns raised1
Delays in amending medication when presenting symptoms indicate a different treatment
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
The Foxhayes Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
The Foxhayes Surgery
Mental health services retain responsibility for prescribing and antipsychotic dose changes when a patient is under specialist care.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to consider or plan alternative pain management during opioid overdose treatment
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
the Princess Alexandra Hospital NHS 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
the Princess Alexandra Hospital NHS Trust
Share opioid reversal guidance through palliative-care educational events and hold collaborative opioid-learning events with the integrated care system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of specific guidance for considering alternative methods of treatment for patients at high risk of acquiring Covid-19
This report raised 3 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.
West Sussex
Concerns raised1
Failure to risk-assess the appropriateness of PEG insertion
This report raised 14 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
Queen Victoria Hospital 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
Queen Victoria Hospital NHS Foundation Trust
Rewrite the Enteral Feeding Guideline to clarify absolute and relative PEG contraindications.
Queen Victoria Hospital NHS Foundation Trust
Use a PEG safety checklist with documented MDT decisions, contraindication checks, stop points and risk assessments.
Queen Victoria Hospital NHS Foundation Trust
Audit prospective PEG practice, including stickers, MDT documentation, consent and checklist use.
Care Quality Commission
Request and review the trust’s completed prospective PEG audit to obtain assurances about safe care and treatment.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
NHS Improvement, NHS England, and the Care Quality Commission, working with the Trust and commissioners, were responsible for ensuring appropriate action.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Pre-operative assessment considers suitability for surgery based on available facilities, while the laboratory agreement requires urgent specimens to be processed within one hour.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Failure to reassess diagnoses and escalate treatment despite continuing clinical decline
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Herefordshire and Worcestershire Health and Care NHS 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
Herefordshire and Worcestershire Health and Care NHS Trust
Hold staff study sessions to discuss case learning and encourage curiosity in clinical situations.
London (East)
Concerns raised2
Failure to reassess treatment options in response to significant treatment delays
Failure to conduct detailed assessment and re-consult treatment options during clinical deterioration
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.
West Yorkshire (East)
Concerns raised1
Failure to escalate treatment options when clinically indicated
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.
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.