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 raised1
Poor communication between radiology staff and clinicians and nurses
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.2
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Action
Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Poor communication of the post-procedure care plan to ward staff
This report raised 22 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
Develop a patient pathway linking ward and radiology teams, requiring pre- and post-procedure observations and clear handover communication.
Stated by Circle Health Group Limited
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Concerns raised1
Failure of nursing staff to raise known risk factors with consultants
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Poor communication between clinical 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.
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 clinical handovers to access microbiology results through ICE and document outstanding results for follow-up and action.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Require staff receiving urgent blood results by telephone to record, sign, date, time and verbally communicate them to medical staff.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure of nursing and medical staff to liaise about patient concerns and clinical attendances
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.4
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Action
Recruit and place a permanent full-time doctor at Darley Court Intermediate Care.
Stated by The Trust -
Action
Increase consultant attendance sessions at Darley Court Intermediate Care beyond the existing two sessions per week.
Stated by The Trust -
Action
Provide Darley Court staff direct access to an out-of-hours GP and require consultation details to be documented in Darley Court medical notes.
Stated by The Trust
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Action
Include the doctor and a senior therapy-team member in the daily morning safety huddle.
Stated by The Trust
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Concerns raised1
Failure of nursing and medical staff to communicate DNAR decisions
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
Reiterate the ward-round standard requiring daily joint nursing and medical staff rounds.
Stated by Walsall Healthcare NHS Trust -
Action
Develop a Ward Board indicator highlighting patients with DNAR decisions for staff handovers and ongoing reference.
Stated by Walsall Healthcare NHS Trust -
Action
Review the DNAR policy for compliance with best practice, including communication requirements.
Stated by Walsall Healthcare NHS Trust
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Action
Conduct peer audits of DNAR form use and continue reviewing them on a rolling basis to assure implementation of disseminated learning.
Stated by Walsall Healthcare NHS Trust
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Concerns raised1
Lack of clarity in communication between the Intervention Radiology team and nursing staff about observations to be carried out
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 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
Redesign the observation-frequency handover sheet by procedure type and require signatures from interventional radiology and receiving-ward nurses at the radiology theatre.
Stated by University Hospitals of Leicester NHS Trust
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Concerns raised1
Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks
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 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
Agree a protocol with St Thomas’ to improve communication and care coordination for patients referred to physical health clinics.
Stated by Cygnet Behavioural Health Limited
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
Responsibility for physical-health care after referral is transferred to St Thomas’ specialists, over whom the hospital has no control.
Stated by Cygnet Behavioural Health Limited
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Concerns raised1
Ward-round planning and preparation relying solely on a brief nursing summary
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 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
Review nursing models of care and generate recommendations for a standardised care-delivery model.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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
Ward rounds have access to the patient's full comprehensive care record and do not rely solely on the nursing summary.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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Concerns raised1
Failure to communicate additional safety and consent requirements for procedures
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
Document accompanying nurses and explicit ward instructions in the electronic CRIS system for imaging communication.
Stated by University Hospitals of North Midlands NHS Trust
Data last updated 7 September 2026