Recurring concern
Unsafe management of operational protocol changes
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Request correctionFirst reported 7 Oct 2014•Latest report 4 Oct 2023
What this concern includes
Includes deficiencies in the management of explicitly identified operational protocol changes, including communication, staff understanding or training, publication, supersession control and implementation of the changed protocol.
Not included
- Excludes generic staff training deficiencies not tied to an operational protocol change.
- Excludes generic communication, documentation or policy-governance failures not specifically concerning an operational protocol change.
- Excludes failures involving the substantive content of a protocol where the issue is not the management or implementation of a change.
- Reports
- 10
- Individual concerns
- 14
- Date range
- 2014–2023
- Stated actions
- 8
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
Unavailability of a revised protocol for triaging patients with mental health problems
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 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
Review the triage protocol and ensure triaging GPs know how to identify the next available routine and soon appointment slots.
Stated by Hereford Medical Group
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 existing GP triage protocol required no significant changes beyond ensuring awareness of available routine and soon appointment slots.
Stated by Hereford Medical Group
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Concerns raised1
Failure to adopt accelerated N-acetylcysteine administration into a standard operating protocol
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.
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 of managerial policy-change controls to prevent recurrence of superseded-policy confusion
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
Audit contacts to the Integrated Front Door and address uncertainty about statutory duties and relevant mental health policies.
Stated by Cambridgeshire County Council -
Action
Clarify which AWOL policy has been superseded.
Stated by Cambridgeshire and Peterborough NHS Foundation Trust
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Concerns raised2
Failure of emergency staff to be aware of the applicable protocol
Lack of a firm, clear training programme for the new protocol
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.2
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Action
Disseminate Joint Operating Procedure and dynamic-risk-assessment guidance through staff briefings, memoranda, meetings, face-to-face sessions, induction and operational assurance activities.
Stated by North East Ambulance Service NHS Foundation Trust -
Action
Audit frontline staff knowledge and awareness of the Joint Operating Procedure.
Stated by North East Ambulance Service 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
Formal collective launch of the Joint Operating Procedure was considered ceremonial because stakeholders had already agreed and used it in daily routines.
Stated by North East Ambulance Service NHS Foundation Trust
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Concerns raised2
Delays in reviewing, amending and publishing revised LOPs
Failure to ensure staff understanding and implementation of operational protocols
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Lack of verification that staff have read and understood protocol changes
Lack of training on the protocol change
Failure to ensure staff awareness of changes to resuscitation policy
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 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
Introduce a clinical-information dissemination procedure using risk-based bulletins with mandatory receipt and understanding confirmation for critical updates, supported by weekly monitoring.
Stated by East Midlands Ambulance Service NHS Trust
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Concerns raised1
Lack of formal training and detailed understanding of the current overdose policy
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
Introduce monthly multidisciplinary substance misuse training for healthcare, discipline and other prison staff.
Stated by Eric Stephens
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Concerns raised1
Lack of training for staff handling welfare check requests in the new policy
This report raised 11 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 formalise changes to the policy for inducting new staff
This report raised 11 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 comprehensive junior-doctor obstetrics and gynaecology induction programme, including orientation, competency assessments, guidance access, support contacts, follow-up and supernumerary work.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
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Concerns raised1
Failure to mandate training on new procedures and protocols for all staff requiring awareness
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026