Standard operating procedure

Referral & Escalation Procedure

The step-by-step procedure for recognising when a situation exceeds a practitioner's competence and for escalating or referring a patient onward safely - covering emergency, urgent same-day and routine pathways.

For Aesthetic ClinicRef BS-AES-SOP-014See a sample (PDF) →
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  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Escalation levels
  • 6. Procedure
  • 7. Communication and safety-netting
  • 8. Records
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 9 (Person-centred care) and Regulation 17 (Good governance)
  • Care Quality Commission (CQC) Fundamental Standards - the Safe and Responsive key questions
  • General Medical Council (GMC) - Good medical practice (working within the limits of competence and referring appropriately)
  • Nursing and Midwifery Council (NMC) - The Code (recognising and working within the limits of competence and escalating concerns)
  • Data Protection Act 2018 and the UK General Data Protection Regulation (UK GDPR) - sharing information with consent

Who it applies to

All practitioners, independent prescribers, registered nurses and clinical support staff at [Organisation Name] involved in assessing, treating or following up patients, and reception staff who take patient contact.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Accident and Emergency (A&E)
The hospital department that assesses and treats people with serious or life-threatening injuries and illness, also called the Emergency Department.
Adverse event
Any unexpected or unwanted occurrence linked to a treatment that harms, or could harm, a patient.
Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Body dysmorphic disorder (BDD)
A mental-health condition in which a person is preoccupied with a perceived flaw in their appearance that others may not notice.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Data Protection Act 2018
The UK law that sets the rules for using people's personal information, working alongside the UK GDPR.
Dermal filler
An injectable gel used to smooth lines or add volume to the face, which can rarely block a blood vessel and cause serious harm.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
Escalation
Raising a concern to a more senior or more competent colleague so they take over or guide a patient's care.
Fundamental standards
The minimum standards of safety and quality below which care must never fall.
General Medical Council (GMC)
The body that registers and regulates doctors in the UK and sets the standards for good medical practice.
General practitioner (GP)
A family doctor based in the community who provides everyday medical care and onward referral.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations that set the legal requirements providers must meet to deliver safe, good-quality regulated care.
Indemnified
Covered by insurance or a similar arrangement that protects against the costs of a claim if something goes wrong in practice.
Independent prescriber
A qualified health professional legally allowed to assess patients and prescribe medicines on their own responsibility.
Intramuscular adrenaline
An injection of adrenaline into a muscle, the emergency first-line treatment for anaphylaxis.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Nursing and Midwifery Council (NMC)
The body that registers and regulates nurses and midwives in the UK and sets the standards in The Code.
Ophthalmology
The branch of medicine dealing with the eye and its disorders, including sight-threatening emergencies.
Red flag
A symptom or sign that points to a serious or time-critical problem needing urgent or emergency action.
Referral
Directing a patient onward to another service or professional for care that is outside the provider's remit.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Safety-netting
Giving a patient clear verbal and written advice on what to watch for, what to do and who to contact if things change or worsen.
SBAR
A structured handover tool - Situation, Background, Assessment, Recommendation - used to communicate a clinical concern clearly.
Scope of competence
The range of activities a practitioner is trained, qualified, indemnified and currently able to perform safely.
Skin necrosis
The death of skin tissue, which can follow a blocked blood vessel and is a serious treatment complication.
Standard Operating Procedure (SOP)
A document setting out the agreed step-by-step way a particular task or situation must be handled.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.
Vascular occlusion
A blockage of a blood vessel, for example by dermal filler, that cuts off blood supply and needs urgent treatment.

How it works

  1. Buy securely with Stripe - instant, no VAT, no account needed.
  2. Download your editable Word file from the link we email you straight away.
  3. Complete the placeholders for your service, then have it approved before use.
  4. Add the optional updates subscription and we keep it current as guidance changes.

Related documents

PolicyAdverse Event Management Policy£54.99
PolicySafeguarding Policy£54.99
PolicyComplaints Policy£54.99
PolicyConsent & Risk Disclosure Policy£54.99

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