Recurring concern
Unreliable communication of patient-care information between clinical staff
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Request correctionFirst reported 21 Aug 2013•Latest report 27 Feb 2026
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
- Individual concerns
- 133
- Date range
- 2013–2026
- Stated actions
- 193
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Deliver safety messages and local teaching to nurses about escalating indicated but unprescribed appliances.
Stated by Medway NHS Foundation Trust -
Action
Audit anti-embolic stocking practice monthly, monitor compliance during ward and drug rounds, and share identified lessons at ward meetings.
Stated by Medway NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Audit patient records monthly for compliance with specialty-consultation recording requirements and discuss identified issues at joint clinical governance meetings.
Stated by Atrumed Ltd
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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.
Responses linked to these concernsEach 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
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Action
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Stated by Calderdale and Huddersfield NHS Foundation Trust
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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Position
The internal investigation could not pursue why laboratory results were not passed on because the recipient could not be identified.
Stated by Calderdale and Huddersfield NHS Foundation Trust
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Position
Automatic laboratory-result availability in the primary record is considered sufficient, removing the need for results to be phoned through or verbally passed on.
Stated by Calderdale and Huddersfield NHS Foundation Trust -
Position
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Stated by Calderdale and Huddersfield NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Require cross-city transfers to include a written nursing handover document recording the patient’s falls risk.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Seek an agreement with Yorkshire Ambulance Service not to accept transfers without a handover document recording falls risk.
Stated by Leeds Teaching Hospitals NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Hold daily multidisciplinary morning report meetings to discuss cases and make appropriate specialty referrals.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Operationalise reinstatement of thrice-weekly joint Critical Care and Microbiology ward rounds.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Scope improvements to recording patient information for patients needing specialist advice while off site.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Work with the Norse supplier to transition to the system’s latest version and additional features.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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Action
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Position
Existing practice of sending GPs clinical letters, care plans and relevant assessment information is considered sufficient for treatment-plan updates.
Stated by Sussex Partnership NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026