First reported 21 Aug 2013•Latest report 27 Feb 2026
Definition
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.
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
124
Distinct published reports
Individual concerns
133
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
193
Described in published responses
Reports over time
Reports 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.
Department of Health and Social Care17
NHS England13
Care Quality Commission7
Barts Health NHS Trust4
Pennine Care NHS Foundation Trust4
University Hospitals of Leicester NHS Trust4
Blackpool Teaching Hospitals NHS Foundation Trust3
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust3
Essex Partnership University NHS Foundation Trust3
Manchester University NHS Foundation Trust3
National Institute for Health and Care Excellence3
Royal London Hospital3
Tameside and Glossop Integrated Care NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Betsi Cadwaladr University LHB2
NHS trust90
Healthcare site20
Ministerial department19
Executive non-departmental public body15
Integrated care board8
Health and social care service regulator7
Multi-service care provider7
Private limited company7
Local health board6
Type not available5
Health professional body4
Independent healthcare provider3
Devolved government2
English county council2
Executive agency2
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Essex
Concerns raised1
Failure to fully impart and understand crucial clinical information
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement Epic as a unified electronic patient record providing real-time access to clinical information and an integrated communication and escalation platform.
Stated by East Suffolk and North Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing escalation and communication pathways are considered appropriate, including consultant review, alternative escalation, and waiting where patients remain stable.
Stated by East Suffolk and North Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to ensure communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Maintain consistent Trust-wide use of seating charts and documentation of allied health professional recommendations in HIVE for communication and care planning.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Extend the Wythenshawe audit of physiotherapy assessments and nursing review processes across the Trust and report findings through hospital quality and safety groups.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust disputes that communication and documentation measures for sitting-out recommendations were isolated to Doyle Ward, stating they apply consistently across all inpatient areas.
Stated by Manchester University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Breakdown of communication about responsibility for penicillin prescription and dispensation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Proactively contact patients with sickle cell disease annually for medication reviews, including Penicillin V prescribing and compliance.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Liaise directly with secondary or tertiary specialists when responsibility for Penicillin V prescribing or dispensing requires clarification.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Move all patients with sickle cell disease to electronic repeat dispensing for Penicillin antibiotics.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Require the on-site pharmacist to communicate uncollected sickle cell disease prescriptions to the practice.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Increase access to shared care records to improve communication between primary and secondary care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Develop greater interoperability of electronic patient records, starting with structured medication information sharing.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the prophylactic penicillin communication concern lies with other bodies.
Stated by Partnership of East London Co-operatives LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without a shared care protocol, the hospital should retain responsibility for care, monitoring and issuing the prescription.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to communicate overnight deterioration and family medication concerns to the on-call doctor
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Provide restorative clinical supervision and professional nurse advocate learning on controlled drugs, communication, challenge and escalation.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Shropshire, Telford and Wrekin
Concerns raised1
Failure of document exchange and communication between gastroenterology and cardiology teams
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Require each inpatient specialty to document and share a standard operating procedure defining referral processes, responsibilities and safety-netting.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Establish a single outpatient-referral email for each specialty, with referrals managed through standard triage and follow-up processes.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Raise a project feasibility request to assess a digital referral-management solution for scoping and potential inclusion on the Trust’s digital roadmap.
Stated by the Shrewsbury and Telford Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Develop and roll out the national Frontline Digitisation Programme, including electronic-record deployment guidance and support for safe implementation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Lack of information sharing between professionals involved in care and treatment
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Hold a post-Inquest debrief with Community and Crisis Response teams to share learning about information sharing.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Review information-sharing protocols for collaboration with professionals in other organisations.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Introduce structured handovers and shared care plans accessible to involved health, care-home and social-care professionals.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Undertake a full review of community mental health social work arrangements, including joint-working arrangements, to clarify roles and responsibilities.
Stated by Essex County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 October 2025.
West Yorkshire (Western)
Concerns raised2
Failure of ward care professionals to communicate concerns about the health impact of collar use
Failure of treating clinicians to communicate with the neurosurgical team about treatment options
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Revise clinical guidance and protocols to establish escalation processes for advice, complications and neurosurgical liaison in cervical spine injury care.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2025.
Action
Develop and implement a collar initiation and management procedure covering consent, risk-benefit decisions, neurosurgical input and escalation.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 September 2025.
Manchester South
Concerns raised1
Fragmented and disjointed storage and sharing of clinical information between professionals
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Continue rolling out and optimising electronic patient records across NHS trusts to improve access to shared patient information.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2025.
Action
Provide support to improve secondary-care organisations’ digital maturity and reduce barriers to sharing clinical information.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 18 June 2025.
Action
Run annual digital maturity assessments for secondary-care organisations to track progress and identify improvements.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 18 June 2025.
Action
Deliver a single patient record bringing patients’ medical records together, beginning rollout in maternity care from 2028.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 18 June 2025.
South London
Concerns raised1
Failure to acknowledge communicated patient risk
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Inner North London
Concerns raised1
Failure to communicate accurate clinical information between ward and medical staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement and embed SBAR communication education in ward inductions, junior-doctor induction, safety huddles, board rounds and medical discussions.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
Action
Introduce and operate an additional mid-shift safety huddle reviewing high-fall-risk patients and changes in condition.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.
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Includes failures to communicate relevant patient care, treatment or risk information between clinical staff responsible for the same patient's care.
