First reported 21 Nov 2013•Latest report 17 Dec 2025
Definition
What this concern includes
Includes failures in the dedicated coordination of referrals between healthcare teams or organisations, including unclear or unshared referral criteria, missing responsibility and communication arrangements, restricted or inappropriate referral routes, and failures to accept, transfer or coordinate referrals.
Not included
Excludes generic inter-team communication or coordination failures where no referral process is involved.
Excludes failures in assessment, treatment or follow-up after a referral has been reliably accepted and coordinated.
Excludes service-capacity or waiting-time deficiencies where referral coordination itself is not the unsafe condition.
Excludes condition-specific referral pathways, including the existing mental-health referral-pathway concern, when that named pathway provides the more specific supported boundary.
Reports
19
Distinct published reports
Individual concerns
23
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
41
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.
Department of Health and Social Care5
Change, Grow, Live2
NHS England2
Adferiad Recovery1
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
County Durham and Darlington NHS Foundation Trust1
Coventry and Warwickshire Partnership NHS Trust1
East Kent Hospitals University NHS Foundation Trust1
Family of Spencer Barr1
Forward Thinking Birmingham1
G4S1
G4S Forensic & Medical Services (UK) Ltd1
Health Centre1
Lancashire Teaching Hospitals NHS Foundation Trust1
NHS trust11
Ministerial department5
Company limited by guarantee2
Executive non-departmental public body2
Integrated care board2
Other public body2
Type not available2
Care-home operator1
Community interest company1
Healthcare site1
Health-system partnership1
Independent healthcare provider1
Local health board1
Multi-service care provider1
Nursing home1
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.
Liverpool and the Wirral
Concerns raised1
Failure to consistently identify and make appropriate referrals to the falls team
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 concerns
Each 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
Action
Review the Falls Policy to determine whether more specific referral guidance should be included.
Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Refer every resident who falls to the Falls Team and inform staff of this approach.
Stated by Activcare Ltd t/a Westwood Hall Nursing Home and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Inner North London
Concerns raised1
Ambiguity in urgent referral terminology and third-party providers’ understanding of available cardiology pathways
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 concerns
Each 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
Action
Update the suspected heart failure pathway to clarify urgent referral routes and align them with two-week and two-to-six-week clinic provision.
Stated by North Central London ICBStated completedThe respondent said that this action was complete when they made their response on 7 April 2026.
Cumbria
Concerns raised1
Failure to make safeguarding referrals when other agencies are thought to be aware
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Audit cases involving self-neglect risk, assess referral, escalation and management oversight, and share findings with partners for practice review.
Stated by Northumberland Children and Adults Safeguarding PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 27 February 2025.
Action
Introduce a multi-agency risk management framework within six months for earlier intervention and referrals involving adults with complex needs and serious-risk concerns.
Stated by Northumberland Children and Adults Safeguarding PartnershipStated plannedThe respondent said that this action was planned when they made their response on 27 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Integrated Care Board is leading work to ensure escalation processes and safeguarding responsibilities are understood across primary care services.
Stated by Northumberland Children and Adults Safeguarding PartnershipRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Lack of clarity in referral and crisis-support processes for patients receiving private and NHS treatment
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 concerns
Each 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.6
Action
Maintain a ratified Private Providers Shared Care Policy defining Trust and private-provider roles and responsibilities.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Make the Private Providers Shared Care Policy accessible on the Trust website and communicate its existence internally and through local GP networks.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Improve and publish prominent website information directing healthcare professionals to urgent mental-health crisis referrals, including the 24/7 crisis line.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Share crisis-referral information externally through social media, website news articles, and campaign materials.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Review the interface between NHS and non-NHS-funded independent health providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
No national or local system provides contact details for every private provider, so referral information cannot feasibly reach all providers.
Stated by South West London and St George'S Mental Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Private providers can refer patients directly to crisis services through the Mental Health Crisis Line, 111, 999 or A&E.
Stated by South West London and St George'S Mental Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The relevant NHS mental health trust is responsible for providing further information about its emergency referral signposting for private providers.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Lack of systems and processes to ensure completion of alcohol liaison team referrals
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 concerns
Each 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
Action
Update the service specification to include electronic contact, risk, signposting, referral and service-exit recording requirements.
Stated by Adferiad Recovery LtdStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Implement and roll out the updated service specification to all staff by the end of September 2023.
Stated by Adferiad Recovery LtdStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Action
Issue communication clarifying the referral process to liaison services and share it with clinical teams across the Health Board.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Review the liaison psychiatry delivery framework with stakeholders and progress revisions through consultation and ratification.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Nottinghamshire
Concerns raised1
Failure to finalise the Standard Operating Procedure for decompression craniectomy monitoring and referral criteria
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 concerns
Each 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
Action
Finalise and circulate a cross-department SOP incorporating NICE guidance, monitoring requirements and referral criteria for decompressive hemicraniectomy.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 July 2023.
Birmingham and Solihull
Concerns raised1
Failure of organisations to accept direct referrals from other agencies
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 concerns
Each 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
Action
Continue working with partner agencies to refine and improve inter-agency referral processes through commissioning review.
Stated by Probation Young Adults Central Team BirminghamStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Develop a fast-track trusted-assessment pathway to expedite mental-health referrals from CGL.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Lack of a standard protocol for routine provision of referral photographs to assist triage
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised1
Failure of teams to understand each other's referral criteria
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised1
Lack of approved documented pathways for referral and treatment of aortic aneurysms
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.9
Action
Publish and distribute the Liverpool Acute Network for Thoracic Aortic Services pathway across the region and on the Trust website.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Produce three regional referral pathways covering Cheshire and Merseyside, Wythenshawe and MRI, and Lancashire including Blackpool.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Publish the Manchester and Lancashire referral pathway documents and distribute the pathways to emergency departments.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2018.
Action
Finalise and obtain approval for the Lancashire and South Cumbria pathway for managing aortic aneurysms.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Share the Lancashire and South Cumbria pathway and clinical algorithm with Medical Directors and Emergency Departments across the vascular network.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 September 2018.
Action
Implement formally agreed written guidance for Greater Manchester acute aortic syndrome referrals and distribute it to covered hospitals and healthcare professionals.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Continue consulting with Liverpool Heart and Chest Hospital and modifying Manchester’s referral guidance in line with wider cardiothoracic strategy and service specifications.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2018.
Action
Publish vascular surgery service specifications requiring networked arrangements and agreed pathways with non-arterial services.
Stated by Caroline Dinenage MPStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Develop a service specification for aortic aneurysm management, identifying specialist hospitals, team responsibilities, referral communication and clear pathways.
Stated by Caroline Dinenage MPStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Formal organisation of thoracoabdominal aortic services and pathways will be addressed by NHS England’s national service specification.
Stated by Lancashire Teaching Hospitals NHS Foundation Trust and Liverpool Heart and Chest Hospital NHS Foundation Trust and Manchester University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England and national cardiac and vascular clinical reference groups are responsible for developing the service specification and addressing aortic aneurysm pathways.
Stated by Caroline Dinenage MPRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in the dedicated coordination of referrals between healthcare teams or organisations, including unclear or unshared referral criteria, missing responsibility and communication arrangements, restricted or inappropriate referral routes, and failures to accept, transfer or coordinate referrals.
