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 communicate prescribed anti-embolic stocking instructions to nursing staff
Failure to discuss patient presentation and prognosis with nursing staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Medway 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.2
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Medway NHS Foundation Trust
Deliver safety messages and local teaching to nurses about escalating indicated but unprescribed appliances.
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Medway NHS Foundation Trust
Audit anti-embolic stocking practice monthly, monitor compliance during ward and drug rounds, and share identified lessons at ward meetings.
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Concerns raised1
Failure to convey key clinical information to medical registrars
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Atrumed Ltd
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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Atrumed Ltd
Audit patient records monthly for compliance with specialty-consultation recording requirements and discuss identified issues at joint clinical governance meetings.
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Concerns raised1
Failure to communicate laboratory results to treating clinicians
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Calderdale and Huddersfield 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.1
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Calderdale and Huddersfield NHS Foundation Trust
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Calderdale and Huddersfield NHS Foundation Trust
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
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Calderdale and Huddersfield NHS Foundation Trust
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
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Calderdale and Huddersfield NHS Foundation Trust
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
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Concerns raised1
Failure to communicate identified falls risk to the receiving ward
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leeds Teaching 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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Leeds Teaching Hospitals NHS Trust
Require cross-city transfers to include a written nursing handover document recording the patient’s falls risk.
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Leeds Teaching Hospitals NHS Trust
Seek an agreement with Yorkshire Ambulance Service not to accept transfers without a handover document recording falls risk.
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Concerns raised1
Failure to communicate prior emergency department attendance to the respiratory consultant
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Norfolk and Norwich University Hospitals 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.1
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Norfolk and Norwich University Hospitals NHS Foundation Trust
Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.
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Concerns raised1
Failure of critical care and microbiology teams to communicate relevant patient information
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Blackpool Teaching Hospitals 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.1
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Blackpool Teaching Hospitals NHS Foundation Trust
Operationalise reinstatement of thrice-weekly joint Critical Care and Microbiology ward rounds.
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Concerns raised1
Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Birmingham Women'S and Children'S NHS Foundation Trust
- University Hospitals of North Midlands 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.4
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University Hospitals of North Midlands NHS Trust
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
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Birmingham Women'S and Children'S NHS Foundation Trust
Scope improvements to recording patient information for patients needing specialist advice while off site.
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Birmingham Women'S and Children'S NHS Foundation Trust
Work with the Norse supplier to transition to the system’s latest version and additional features.
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Birmingham Women'S and Children'S NHS Foundation Trust
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
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Concerns raised1
Lack of a clear procedure for Care Coordinators to update GPs about changed treatment plans
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership 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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Sussex Partnership NHS Foundation Trust
Existing practice of sending GPs clinical letters, care plans and relevant assessment information is considered sufficient for treatment-plan updates.
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Concerns raised1
Failure to verbally communicate increased suicidal risk to the responsible nurse
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 update the responsible psychiatrist so that the position can be reconsidered
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026