Recurring concern
Failure to reliably identify and communicate individual patient risk factors
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Request correctionFirst reported 20 Nov 2013•Latest report 13 Jan 2025
What this concern includes
Includes failures to identify, assess, document or communicate individual patient risk factors to the clinicians responsible for the patient’s care, including failures to raise known risk factors with consultants and failures of mechanisms intended to ensure relevant clinicians are aware of them.
Not included
- Excludes generic clinical communication, handover or record-keeping deficiencies where individual patient risk factors are not the material unsafe object.
- Excludes risk-assessment failures confined to a separately named hazard or pathway, such as VTE, self-harm, mental-health or pregnancy risk, when that named concern provides the more specific supported boundary.
- Excludes failures to act on risk factors after they have been reliably identified and communicated, unless the identification or communication process is also deficient.
- Excludes generic organisational risk-assessment criteria or staff competence concerns that are not specifically about identifying or communicating individual patient risk factors.
- Reports
- 11
- Individual concerns
- 12
- Date range
- 2013–2025
- Stated actions
- 18
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
Lack of a mechanism to identify and communicate individual patient risk factors
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.
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
Implement an electronic patient record providing staff with accessible medication details and individual patient risk factors.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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Concerns raised2
Failure to use direct contact to understand identified risk factors
Failure to assess how multiple risk factors combine to increase risk
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.2
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Action
Raise awareness of contacting patients on leave when concerns arise through supervision and an inpatient learning forum.
Stated by Pennine Care NHS Foundation Trust -
Action
Continue booking staff onto Clinical Risk Formulation and STORM training, while monitoring uptake and compliance with essential-to-role training.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to identify all patient factors relevant to the clinical indication for and safety of ERCP before the procedure
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.
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
Implement the redesigned Medway-based ERCP referral pathway with expanded clinical-risk and consent information fields.
Stated by Nottingham University Hospitals NHS Trust
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Concerns raised1
Failure to communicate previous hoarding incidents to the GP
This report raised 7 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
Review care-note wording for medication non-adherence and hoarding incidents.
Stated by PENTRE LODGE CARE HOME LIMITED -
Action
Establish direct liaison and incident-notification arrangements with GPs, mental health services, care teams, and police for relevant health and absconding events.
Stated by PENTRE LODGE CARE HOME LIMITED
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Concerns raised1
Failure to document patient vulnerabilities for radiographer use
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 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 communicate suspected illicit drug use and associated ward-leaving risk to nursing staff
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.1
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Action
Remind nursing teams to document suspected illicit drug use in care plans and include it in nursing handovers.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to circulate important clinical risk information to treating clinicians
This report raised 7 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
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce the approved PARIS electronic clinical record system across Manchester services.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure of software systems to communicate allergy markers to prescribing clinicians
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
Introduce a new electronic clinical note that includes patient allergies.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Explore the IT infrastructure interface between the electronic medication and patient record systems.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Migrate the Emergency Department onto the Trust-wide server to improve access to electronic medication records.
Stated by Great Western Hospitals 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
The electronic handover system cannot be tailored to place key information, such as allergies, at the top for individual organisations.
Stated by Great Western Hospitals NHS Foundation Trust
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Concerns raised1
Failure of nursing staff to raise known risk factors with consultants
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.
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 communicate the patient's total number of falls to all visiting staff
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.4
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Action
Revise and publish the falls policy and post-falls checklist to specify NICE-based neurological observation frequency and duration after suspected or confirmed head injury.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Require falls risk and falls information in bedside handovers and safety briefings, with observational audits, feedback, and re-audit of information-sharing gaps.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Implement filing of post-falls checklists with physiological and neurological observation charts for daily multidisciplinary team review of patients’ multiple falls.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Action
Issue and disseminate a Trust-wide Patient Safety Alert covering neurological observations, post-falls checklist completion and filing, and inclusion of falls information in briefings and handovers.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The recommended safety actions are primarily the responsibility of the hospital trust.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
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Position
The hospital trust’s action plan is considered to satisfactorily address all concerns and recommended actions.
Stated by DRS GIBB MURCH GILLARD BOWYER & GEARY
Data last updated 7 September 2026