Recurring concern

Unreliable communication of patient-care information between clinical staff

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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
Individual concerns: 133
Date range: 2013–2026
Stated actions: 193

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

27 Sep2013
Avon
Concerns raised1
1. Inadequate communication between the neonatal intensive care and cardiac units
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 3
1. Action
  Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
2. Action
  Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
3. Action
  Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.
  Stated by Bristol NHS Foundation TrustStated planned
AI-generated summary

Rose Jean COLES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate communication between the neonatal intensive care and cardiac units
Wider context from the report
“Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”
Source location
Rose Jean COLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

Verbatim wording from the response
“Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

Verbatim wording from the response
“| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

Verbatim wording from the response
“| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response
20 Sep2013
Leicester City and South Leicestershire
Concerns raised1
1. Failure to communicate all known information to attending healthcare professionals
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 1
1. Action
  Implement a protocol requiring family notification and completion and sharing of communication sheets after GP or out-of-hours healthcare professional visits.
  Stated by The Manor Residential & Nursing Care HomeStated completed
AI-generated summary

Joan Mary Jones · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Joan Mary Jones, a resident of a care home with Alzheimer's dementia, became unwell on 23 September 2012 and later deteriorated following an aspiration episode. She died on 1 October 2012; the inquest recorded bilateral bronchopneumonia due to locally advanced adenocarcinoma of the large bowel and Alzheimer's dementia. Concerns included failure to escalate her care and failure to communicate relevant information to attending healthcare professionals, resulting in a missed opportunity to treat and an inappropriate care package.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate all known information to attending healthcare professionals
Wider context from the report
“(1) The staff did not escalate Mrs Jones' care when they should have done (2) The staff did not communicate all that was known to them and therefore attending health care professionals were unable to make fully informed decisions (3) Due to the lack of communication, an appropriate package of care was not put in place for Mrs Jones (4) These omissions (failure to escalate and the lack of communication with other attending health care professionals) together or alone, could in future circumstances cause or contribute to death. ”
Source location
Joan Mary Jones · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a protocol requiring family notification and completion and sharing of communication sheets after GP or out-of-hours healthcare professional visits.

Verbatim wording from the response
“On 19th September 2013 a memo was sent to all the unit leads to ensure that following any input from GP's and out of hours nurses, doctors the family must be contacted, that the communication sheet must be completed following any discussions, involvement with any health care professionals. That these communications sheets must be shared with health care professionals and completed after each visit by health care professionals. These visits must be communicated to the family.”

Source location
Response from The Manor
Page 1 · response
Published 27 January 2014
Open published response
5 Sep2013
Leicester City and South Leicestershire
Concerns raised1
1. Failure to share known bleeding information with other health care 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 3
1. Action
  Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  Continue implementing mobile working so community nursing and therapy staff can access patient records in patients’ homes and communicate with linked GP practices.
  Stated by Leicestershire Partnership NHS TrustStated in progress
3. Action
  Commission a review and improvement of communication processes operating within the Single Point of Access.
  Stated by Leicestershire Partnership NHS TrustStated planned
AI-generated summary

Labuben Amarsi Vaghadia · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs Vaghadia developed bleeding after receiving an anticoagulant injection for suspected deep vein thrombosis and died in hospital on 27 August 2012 from haemorrhage and haematoma of the abdominal wall. Concerns included the community nurse administering a further anticoagulant injection without seeking medical advice despite knowing about the bleeding, failing to share that information with other healthcare professionals, and lacking training, experience, and insight into the potential risks of her actions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share known bleeding information with other health care professionals
Wider context from the report
“(2) Although the nurse had full knowledge of the bleeding she did not share this with other health care professionals when she spoke to them. If she had there was a real possibility that Mrs Vaghadia would have been admitted sooner. In this instance, the expert opined that on a balance of probabilities had Mrs Vaghadia been admitted sooner the outcome was unlikely to have been different. Nevertheless, full and appropriate information sharing is paramount and the nurse’s actions fell short of her professional duties and could have caused an adverse outcome. ”
Source location
Labuben Amarsi Vaghadia · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Re-inform CHS healthcare professionals about medicines-management standards, communication responsibilities, relevant case learning, and the community medicines SOP through email cascades, briefings, meetings, and SOP reissue.

Verbatim wording from the response
“It is accepted fully that part of a health professional's responsibility to communicate all relevant information to other clinicians and organisations on the specific details of a patient's condition. The CHS Division will now re-inform all health care professionals about their professional responsibility regarding this issue via a system of email cascade. Specifically the message for compliance with NMC Standards for Medicines Management will be given. Ensuring the message is conveyed will be achieved by cascading the information via their communications lead using direct emails to staff, the inclusion of key learning points of the case within the monthly briefing paper, and dissemination through the professional nurses monthly meeting by the lead nurses for physical and mental health.”

Source location
2013-0201-Response-by-Leicestershire-Partnership-NHS
Page 2 · response
Published 5 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue implementing mobile working so community nursing and therapy staff can access patient records in patients’ homes and communicate with linked GP practices.

Verbatim wording from the response
“For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.”

Source location
2013-0201-Response-by-Leicestershire-Partnership-NHS
Page 2 · response
Published 5 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Commission a review and improvement of communication processes operating within the Single Point of Access.

Verbatim wording from the response
“For further assurance I advise that within CHS division they are implementing a mobile working solution allowing all community nursing and therapy staff to access the patients' notes in their own homes. Many GP practices are linked via this IT solution allowing them the ability to communicate directly with the nurse and vice versa within the clinical record. Systems are already in place for organisations to use the Single Point of Access (SPA) for the Division as a central route for communication. External management consultancy has also been commissioned to review and improve the processes operating within the SPA.”

Source location
2013-0201-Response-by-Leicestershire-Partnership-NHS
Page 2 · response
Published 5 September 2013
Open published response
21 Aug2013
West Sussex
Concerns raised1
1. Failure to communicate risk-care-planning issues among all MDT members
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.
AI-generated summary

Mr Walker · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate risk-care-planning issues among all MDT members
Wider context from the report
“(1) The consideration of, contribution to and preparation involved in risk care planning for Mr Walker was insufficient in its scope and depth in order to provide any informed basis on which an active and proper assessment of his continuing risk (factors) could be made. Properly detailed, and the issues communicated amongst all members of the MDT, this may have better informed thinking with regard to the observation levels set. It is of concern that this risk care plan was neither revisited nor revised. ”
Source location
Mr Walker · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate communication between the neonatal intensive care and cardiac units

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

Concerns raised1

Failure to communicate all known information to attending healthcare professionals

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

Concerns raised1

Failure to share known bleeding information with other health care professionals

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

Concerns raised1

Failure to communicate risk-care-planning issues among all MDT members

Actions described in response 3

Actions described in response 1

Actions described in response 3