Recurring concern
Failure to reliably notify responsible consultants about admissions and significant clinical changes
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Request correctionFirst reported 13 Dec 2013•Latest report 3 Dec 2024
What this concern includes
Includes failures to identify, route, communicate, acknowledge or escalate material information about a patient's admission or significant clinical change to the consultant responsible for the patient's care, including pre-admission risk information and significant events requiring consultant review.
Not included
- Excludes generic communication or handover failures where notification to a responsible consultant is not the bounded safety control.
- Excludes failures in consultant review or clinical leadership after the consultant has been reliably notified.
- Excludes notifications to GPs, families, emergency services or non-consultant clinicians unless the assertion directly concerns the responsible consultant notification process.
- Excludes routine clinical information that does not materially affect admission awareness, senior review or patient-safety decisions.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2013–2024
- Stated actions
- 7
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
Failure to inform and consult the consultant about the clinical presentation
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 inform the consultant anaesthetist about patients and their medical co-morbidities before admission
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
Create a dedicated electronic referral pathway for high-risk clinics and formalise patient risk assessments visible to relevant pre-operative staff.
Stated by Ashford and St Peter'S Hospitals NHS Foundation Trust
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Concerns raised1
Delay in escalating falls to the responsible consultant
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.
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
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to provide timely obstetric consultant supervision after emergency admission
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
Implement daily consultant review of patients on Joan Booker Ward, with labour ward consultant cover when usual consultants are unavailable.
Stated by Ashford and St Peter'S Hospitals NHS Foundation Trust
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Concerns raised1
Failure to ensure that the responsible consultant is made aware of worsening symptoms after discharge
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
Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.
Stated by Black Country Healthcare NHS Foundation Trust
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Concerns raised1
Failure to inform the consultant of the patient and imminent self-discharge before discharge
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
Notify consultants within 12 hours when their patient self-discharges from hospital.
Stated by The Trust
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Concerns raised1
Lack of a reliable method for notifying the responsible Consultant of patient admission
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
Use admission-checklist sign-offs to confirm doctor clerking, physical examination, and consultant notification of hospital admissions.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Audit compliance with admission clerking and consultant-notification requirements.
Stated by Greater Manchester Mental Health 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
Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
Stated by Department of Health and Social Care
Data last updated 7 September 2026