Recurring concern
Unreliable communication of patient-care information between clinical staff
- 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
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 124 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Failure to clearly record treatment plans between transferring and receiving clinical staff
Failure to agree treatment plans between transferring and receiving clinical staff
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Cornwall Partnership NHS Foundation Trust
- Royal Cornwall Hospitals NHS Trust
Stated actions 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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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
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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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
The existing Treatment Escalation Plan adequately specified escalation to acute hospital if deterioration occurred, despite omission from the handover form.
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Concerns raised1
Failure to communicate all relevant patient information to doctors dosing warfarin
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of Leicester NHS Trust
Stated actions 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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University Hospitals of Leicester NHS Trust
Re-emphasised clear anticoagulation communication, shared case learning with clinical leaders and forums, and delivered repeated daily-brief reminders to clinical teams.
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University Hospitals of Leicester NHS Trust
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
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Concerns raised1
Lack of clear guidance for communication of test results and patient presentation across specialisms and team roles
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring 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 provide staff with clear information about food and fluid refusal duration and warning signs
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cardiff & Vale University LHB
Stated actions 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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Cardiff & Vale University LHB
Establish and train staff on a joint food and fluid refusal policy at HMP Cardiff.
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Concerns raised1
Persisting relationship and communication problems between maternity and neonatal staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of Derby and Burton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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University Hospitals of Derby and Burton NHS Foundation Trust
Run the Culture and Civility improvement project and track its action plan through programme governance.
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University Hospitals of Derby and Burton NHS Foundation Trust
Publish and socialise the Culture and Civility workshop outputs and charter.
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University Hospitals of Derby and Burton NHS Foundation Trust
Expand Team of the Shift huddles to include neonatal team members.
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University Hospitals of Derby and Burton NHS Foundation Trust
Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
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Concerns raised1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Linked response
- Stockton Care Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Stockton Care Limited
Communicate the coroner’s concerns and effective communication requirements to all staff.
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Stockton Care Limited
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
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Stockton Care Limited
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
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Stockton Care Limited
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
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Stockton Care Limited
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
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Concerns raised1
Failure of the bleep system to convey information electronically
Linked response
- Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Betsi Cadwaladr University LHB
Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
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Betsi Cadwaladr University LHB
Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.
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Betsi Cadwaladr University LHB
Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.
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Betsi Cadwaladr University LHB
Decide the specific future communication solution using the results of technical testing with frontline clinicians.
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Concerns raised1
Lack of a clear system for communication between teams about patient progress and missed appointments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Worcestershire Acute Hospitals NHS Trust
Stated actions 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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Worcestershire Acute Hospitals NHS Trust
Develop a standard operating procedure for monitoring potentially cancerous lesions, including information transfer between teams.
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Worcestershire Acute Hospitals NHS Trust
Develop a clear process for handing patients from Cancer Services to departmental teams when they leave active cancer tracking.
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Concerns raised1
Failure to share key patient information between clinicians and the nursing team
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring 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
Breakdowns in communication between inpatient staff and the CMHT
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026