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 raised1
Failure to ensure communication between interventional radiology and hepatology specialists
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health 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.1
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Barts Health NHS Trust
Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Barts Health NHS Trust
Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
-
Concerns raised1
Failure to share and escalate delayed antibiotic treatment information
This report raised 10 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.
-
Concerns raised1
Lack of communication between hospital departments about responsibility for patient care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- 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.3
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University Hospitals of North Midlands NHS Trust
Agree the renal admission pathway with advice clarifying the reason for referral.
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University Hospitals of North Midlands NHS Trust
Amend Trust Internal Professional Standards to reduce failures caused by misunderstanding between departments.
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University Hospitals of North Midlands NHS Trust
Escalate and document patients requiring specialty care through Emergency Department huddles and the Huddle Log.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University Hospitals of North Midlands NHS Trust
The absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
-
Concerns raised1
Failure to seek clarification of unclear prescribing advice
This report raised 3 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.
-
Concerns raised1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
This report raised 1 other concern. 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.
-
Concerns raised1
Failure to directly inform senior clinical staff of disclosed suicide risk
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Devon University Healthcare 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.3
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Royal Devon University Healthcare NHS Foundation Trust
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
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Royal Devon University Healthcare NHS Foundation Trust
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
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Royal Devon University Healthcare NHS Foundation Trust
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Royal Devon University Healthcare NHS Foundation Trust
Existing training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
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Royal Devon University Healthcare NHS Foundation Trust
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
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Concerns raised1
Failure of clear communication between clinicians and nursing staff
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Doncaster and Bassetlaw 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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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Implement a CDU pathway document to support communication between the main hospital department and CDU on admission.
-
Concerns raised2
Failure to communicate deterioration between ward doctors and nursing staff
Failure of consultants to communicate about patients with ward staff
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Tameside and Glossop Integrated Care 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
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
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Concerns raised1
Failure to formally record and communicate important messages between staff members
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Norfolk and Suffolk 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 Suffolk NHS Foundation Trust
Issue an internal alert directing inpatient wards to reflect on how information from different sources is received and captured.
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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Norfolk and Suffolk NHS Foundation Trust
No single evidence-based communication tool can currently be implemented to eliminate the risk of important information failing to reach ward rounds.
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Concerns raised1
Failure to communicate accurate overdose information to liaison psychiatry
This report raised 4 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
Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.
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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Cardiff & Vale University LHB
The documentation error stating two tablets were taken did not influence the clinical decision because clinicians knew twenty tablets had been taken.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026