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.
Cardiff & the Vale of Glamorgan
Concerns raised1
Failure to share and act promptly on nursing staff concerns
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Failure to communicate labour-stage duration effectively to relevant clinical staff
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.1
Action
Require clearer clinical communications, including precise requests for action, through staff reflection and management discussion.
Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A communication pro forma will not be introduced because completing it during emergencies could delay effective action.
Stated by University Hospitals of Leicester NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Failure of communication between junior doctors and radiologists causing delay in CTPA
This report raised 6 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Yorkshire (Western)
Concerns raised1
Failure of two-way communication about prescribing between primary and secondary care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Blackpool and the Fylde
Concerns raised1
Failure to communicate relevant family medical history effectively to hospital staff involved in care
This report raised 2 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure to communicate significant proteinuria to the ward
This report raised 5 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.3
Action
Refer the case for inclusion in formal Foundation doctor teaching on the significance of marked proteinuria.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2014.
Action
Share the incident at departmental governance meetings to reinforce recognition and communication of significant proteinuria.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2014.
Action
Revise the emergency department transfer checklist to include results of tests performed before admission.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 5 May 2014.
West London
Concerns raised1
Failure to communicate medication changes between the GP practice and responsible clinician
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.5
Action
Review processes for recording medications across different healthcare sectors.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust considered its communication systems effective in this case and did not identify a need to change them.
Stated by Central and North West London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Deficiencies in communication of clinical information between staff
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to report a documented temperature rise to medical staff
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.3
Action
Use an electronic-system prompt to indicate when abnormal observations need communicating to senior staff.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2014.
Action
Hold regular Emergency Department board rounds so each patient is discussed with senior medical staff.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2014.
Action
Reconfigure the electronic clinical information system to create a visible consultant alert when vital signs fall outside normal parameters.
Stated by the Dudley Group NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 April 2014.
West Sussex
Concerns raised1
Lack of a protocol for pharmacist-clinician discussion of queried drug dosages
This report raised 2 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
Issue a directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.
Stated by Surrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2014.
Action
Reiterate the medication-screening procedure requiring direct discussion between prescribing clinicians and screening or dispensing pharmacists, with escalation to another prescriber when necessary.
Stated by Surrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2014.
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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.
