Recurring concern
Unreliable communication of patient-care information between clinical staff
First 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 raised1
Failure to communicate explicit requirements between medical and nursing teams
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
Use a written high-vaginal-swab protocol requiring cervical-speculum visualization, documentation of findings, and GP review of abnormalities.
Stated by Stonefield Street Surgery
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Concerns raised1
Failure to communicate suspected illicit drug use and associated ward-leaving risk to nursing staff
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
Remind nursing teams to document suspected illicit drug use in care plans and include it in nursing handovers.
Stated by Barts Health NHS Trust
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Concerns raised1
Delays in escalating NEWS to medical staff
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 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
Lack of a system for communication between treating specialty consultants about potential ongoing risks of simultaneous specialty-specific treatments
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 of communication with family and between Trust 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 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 use one Trust-wide IT system for information sharing between professionals involved in care
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 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
Lead the Global Digital Exemplar programme to digitise and connect health systems and improve secure information sharing.
Stated by NHS England -
Action
Work with Local Health and Care Record Exemplars to establish local longitudinal records enabling authorised staff to access permitted patient information.
Stated by NHS England
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
NHS England leads work to address secure cross-service record sharing and should provide information about its progress.
Stated by Department of Health and Social Care
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Concerns raised1
Poor communication between the Orthotics Department and ward-based 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.1
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Action
Provide all Sandwell General Hospital wards with Orthotics contact details and substantive administrative support for timely referrals.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised1
Failure to circulate important clinical risk information to treating clinicians
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.3
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Action
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce the approved PARIS electronic clinical record system across Manchester services.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Lack of a clear system for updating GPs about patient disengagement when the medical team is not involved in 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 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
Create an action plan addressing the concerns raised in the PFD report.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised1
Failure to communicate relevant preliminary examination information to Doctors
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.1
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Action
Reinforce nurses’ recording of relevant care and notification of reviewing clinicians, including through local nursing induction.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Data last updated 7 September 2026