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Unclear and unreliable GP access and referral pathways 17 29 20 Apr 2026 Unreliable clinical assessment and management of eating disorders 5 18 14 Feb 2024 Failure to maintain safe care and support during service transitions 7 10 23 Jun 2025 Incomplete consideration of relevant factors in falls risk assessments 7 14 17 Nov 2023 Unreliable access to appropriate addiction support 7 11 30 Apr 2021 Insufficient CAMHS staffing capacity and competence for safe care 4 9 30 Apr 2024 Failure to reliably notify primary care of changes affecting patient care 21 35 15 Oct 2025 Failure to reliably identify and communicate individual patient risk factors 11 16 13 Jan 2025 Insufficient dietetic staffing capacity for timely patient care 3 4 3 Jun 2024 Unreliable safe-return arrangements after police custody release 2 13 8 Jun 2023 Unreliable patient contact during urgent recall and follow-up 3 6 11 Jan 2023 Unreliable escalation and referral in eating disorder care 6 23 7 Jan 2026 Failure of ambulance information systems to transfer safety-critical clinical and operational information 12 20 18 Jun 2025 Unreliable Gateway referral and assessment process 2 2 4 Oct 2019 Insufficient inpatient detoxification capacity 2 7 18 Dec 2017 Unreliable vulnerability assessment in emergency accommodation decisions 2 2 9 Mar 2026 Unreliable response to suicidal communications by text 2 5 8 Aug 2025 Unreliable communication of significant academic decisions and support actions to students 5 8 19 Jan 2024 Failure to recognise distress and increased risk communicated through behaviour 3 11 4 May 2024 Failure to provide timely adult ADHD assessment and treatment 4 4 5 Feb 2026 Unreliable referrals to acute dietetic services 3 4 6 Nov 2018 Unreliable recognition and response to alcohol withdrawal 6 10 3 Sep 2025 Inadequate pastoral support systems for identifying and responding to welfare concerns 6 9 10 Jul 2024 Unreliable Child in Need assessments for vulnerable young people 2 6 19 Feb 2023 Failure to adapt healthcare communication for neurodivergent patients and parents 2 4 27 May 2026