First reported 28 Apr 2014•Latest report 28 Aug 2025
Definition
What this concern includes
Includes failures of controls dedicated to cervical-collar safety, including availability and provision of suitable collars, fitting and application, communication between relevant clinical and supplying teams, and clinical review of concerns about the collar’s impact on the patient.
Not included
Excludes generic communication, equipment, staffing or clinical-review deficiencies unless they are specifically tied to cervical-collar safety.
Excludes unrelated spinal immobilisation or patient-handling concerns where cervical-collar provision or management is not the identified unsafe condition.
Excludes general treatment delays or diagnostic failures that do not materially concern the safety of cervical-collar use.
Reports
4
Distinct published reports
Individual concerns
10
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
14
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.
Calderdale and Huddersfield NHS Foundation Trust2
Bristol NHS Foundation Trust1
Leeds Teaching Hospitals NHS Trust1
Sandwell and West Birmingham Hospitals NHS Trust1
Taycare Medical Limited1
NHS trust4
Private limited company1
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.
West Yorkshire (Western)
Concerns raised3
Failure to assess the risks and benefits of collar use and support an informed decision
Failure of ward care professionals to communicate concerns about the health impact of collar use
Failure by those in charge of care to consider concerns about the impact of collar use
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.3
Action
Develop and implement a collar initiation and management procedure covering consent, risk-benefit decisions, neurosurgical input and escalation.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2025.
Action
Revise electronic care plans to document collar-related risk-benefit discussions and informed consent.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2025.
Action
Revise clinical guidance and protocols to establish escalation processes for advice, complications and neurosurgical liaison in cervical spine injury care.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2025.
West Yorkshire (Western)
Concerns raised3
Inadequate guidelines for the use of Aspen collars
Inadequate training for applying and fixing collars to patients' needs
Ineffective communications about collar fitting and patients' general care
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.3
Action
Supply each Aspen collar with applicable manufacturer instructions and leave those instructions with the patient after fitting.
Stated by Taycare Medical LimitedStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Maintain qualified orthotist training, probationary mentoring and mock fittings to assess competence in Aspen-collar application and fixing.
Stated by Taycare Medical LimitedStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Action
Complete a review of communication effectiveness between CHFT, LTHT and TayCare regarding Aspen-collar fitting and patient care.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The decision to use an Aspen collar rests with Leeds Teaching Hospitals NHS Trust, not Calderdale and Huddersfield NHS Foundation Trust.
Stated by Calderdale and Huddersfield NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
TayCare follows manufacturer fitting guidelines and does not create clinical guidelines; treating doctors decide whether an Aspen collar is used.
Stated by Taycare Medical LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bespoke training provided by TayCare when required is considered the safest model because Calderdale and Huddersfield NHS Foundation Trust sees few Aspen-collar patients.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Manufacturer instructions and qualified orthotists are considered sufficient to achieve appropriate patient-specific collar fitting and training.
Stated by Taycare Medical LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
TayCare has no authority to order, arrange or provide training for NHS staff.
Stated by Taycare Medical LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing communication between the Trusts and TayCare is considered timely, clear, concise and informative, with no delays requiring further work.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Poor systems for providing patient collars
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.3
Action
Train Trauma and Orthopaedics clinicians to apply Miami J collars out of hours.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 March 2018.
Action
Hold and daily replenish a stock of Miami J collars on the Newton 3 ward.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 March 2018.
Action
Provide all Sandwell General Hospital wards with Orthotics contact details and substantive administrative support for timely referrals.
Stated by Sandwell and West Birmingham Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 March 2018.
Avon
Concerns raised3
Failure to raise concerns about inadequate neck immobilisation
Failure to properly immobilise the neck of patients with cervical spine fractures
Unavailability of suitable cervical collars
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.5
Action
Clarify handover communication when a rigid collar is not applied, including reasons, interim neck-care requirements and reattempt timing.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 April 2014.
Action
Re-publicise the hard-collar safety alert across the Medical Directorate and Trustwide clinical directorates.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 April 2014.
Action
Include the hard-collar safety alert in future medical induction for new junior medical staff.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 April 2014.
Action
Report the Regulation 28 findings to the Medical Directorate’s clinical governance agenda.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 April 2014.
Action
Establish a central Emergency Zone storage location for rigid cervical collars.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Further collar application was not pursued because the patient could not tolerate collars and persistence or sedation risked causing greater harm and distress.
Stated by Bristol NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures of controls dedicated to cervical-collar safety, including availability and provision of suitable collars, fitting and application, communication between relevant clinical and supplying teams, and clinical review of concerns about the collar’s impact on the patient.
