Recurring concern

Unreliable communication of patient-care information between clinical staff

First to latest report 21 Aug 2013 — 27 Feb 2026

Reports that mention this concern
124
Times this concern has been raised
133
Stated actions linked to this concern
193

What this concern includes

Includes failures to communicate relevant patient care, treatment or risk information between clinical staff responsible for the same patient's care.

What is not included
  • Formal handover processes where handover itself is the more specific unsafe control
  • Communication between separate organisations or agencies governed by a named information-sharing process
  • Documentation failures where relevant information was otherwise reliably communicated
  • Failure to act after information was reliably communicated

Reports and published responses 124 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Avon

    AI-generated summary

    Rose Jean COLES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate communication between the neonatal intensive care and cardiac units

    Wider context from the report

    “Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”

    Source location

    Rose Jean COLES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

    Verbatim wording from the response

    “Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

    Verbatim wording from the response

    “| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

    Verbatim wording from the response

    “| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

  2. Leicester City and South Leicestershire

    AI-generated summary

    Joan Mary Jones · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Joan Mary Jones, a resident of a care home with Alzheimer's dementia, became unwell on 23 September 2012 and later deteriorated following an aspiration episode. She died on 1 October 2012; the inquest recorded bilateral bronchopneumonia due to locally advanced adenocarcinoma of the large bowel and Alzheimer's dementia. Concerns included failure to escalate her care and failure to communicate relevant information to attending healthcare professionals, resulting in a missed opportunity to treat and an inappropriate care package.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate all known information to attending healthcare professionals

    Wider context from the report

    “(1) The staff did not escalate Mrs Jones' care when they should have done (2) The staff did not communicate all that was known to them and therefore attending health care professionals were unable to make fully informed decisions (3) Due to the lack of communication, an appropriate package of care was not put in place for Mrs Jones (4) These omissions (failure to escalate and the lack of communication with other attending health care professionals) together or alone, could in future circumstances cause or contribute to death. ”

    Source location

    Joan Mary Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a protocol requiring family notification and completion and sharing of communication sheets after GP or out-of-hours healthcare professional visits.

    Verbatim wording from the response

    “On 19th September 2013 a memo was sent to all the unit leads to ensure that following any input from GP's and out of hours nurses, doctors the family must be contacted, that the communication sheet must be completed following any discussions, involvement with any health care professionals. That these communications sheets must be shared with health care professionals and completed after each visit by health care professionals. These visits must be communicated to the family.”

    Source location

    Response from The Manor
    Page 1 · response
    Published 27 January 2014

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Labuben Amarsi Vaghadia · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to share known bleeding information with other health care professionals

    Wider context from the report

    “(2) Although the nurse had full knowledge of the bleeding she did not share this with other health care professionals when she spoke to them. If she had there was a real possibility that Mrs Vaghadia would have been admitted sooner. In this instance, the expert opined that on a balance of probabilities had Mrs Vaghadia been admitted sooner the outcome was unlikely to have been different. Nevertheless, full and appropriate information sharing is paramount and the nurse’s actions fell short of her professional duties and could have caused an adverse outcome. ”

    Source location

    Labuben Amarsi Vaghadia · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.

    Verbatim wording from the response

    “It is accepted fully that part of a health professional's responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professional responsibility regarding this issue via a system of email cascade. Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health.”

    Source location

    2013-0201-Response-by-Leicestershire-Partnership-NHS
    Page 2 · response
    Published 5 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue implementing mobile working so community nursing and therapy staff can access patient records in patients’ homes and communicate with linked GP practices.

    Verbatim wording from the response

    “For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.”

    Source location

    2013-0201-Response-by-Leicestershire-Partnership-NHS
    Page 2 · response
    Published 5 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission a review and improvement of communication processes operating within the Single Point of Access.

    Verbatim wording from the response

    “For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.”

    Source location

    2013-0201-Response-by-Leicestershire-Partnership-NHS
    Page 2 · response
    Published 5 September 2013

    Open published response

  4. West Sussex

    AI-generated summary

    Mr Walker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate risk-care-planning issues among all MDT members

    Wider context from the report

    “(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”

    Source location

    Mr Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026