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.
Essex
Concerns raised1
Failure to share all available information with the acute Trust nurse
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 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.4
Action
Develop and expand the Shared Care Record to provide unified access to patient information across partner services.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Disseminate Shared Care Record notifications, guidance and videos to emergency department clinical staff during rollout.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Implement the NOVA unified electronic patient record across acute, community and mental health services.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Develop a unified electronic patient record across EPUT and MSEFT, including bidirectional primary-care integration.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Stated by Mid and South Essex NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Inner South London
Concerns raised1
Failure of communication between D2A therapists and District Nurses
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 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
Conduct further multi-agency discharge events to improve communication and joint working.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated plannedThe respondent said that this action was planned when they made their response on 29 January 2025.
Action
Establish and disseminate an escalation and information-sharing pathway across community services, with ongoing monitoring and audit.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
Action
Maintain regular Discharge to Assess–District Nursing meetings and a communication champion to oversee information exchange and care-plan adherence.
Stated by Lewisham and Greenwich NHS Trust and London Borough of LewishamStated completedThe respondent said that this action was complete when they made their response on 29 January 2025.
Devon, Plymouth and Torbay
Concerns raised1
Failure to achieve clear communication of key information within community mental health teams
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.2
Action
Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.
Stated by Pembroke Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Position
Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Stated by NHS Devon Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of specialties to communicate about patients’ plans and actions
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.
Staffordshire and Stoke-on-Trent
Concerns raised1
Reliance on manual transcription of treatment decisions between medical notes
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
Develop a digital vision and strategy including a goal for a new electronic patient record across the Integrated Care System.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Action
Draft a business case with the Integrated Care System to apply for NHS funding for an interoperable electronic patient record.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
West Yorkshire (Western)
Concerns raised1
Failure of communication between consultant obstetric and anaesthetic staff in time critical situations
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.5
Action
Strengthen the anaesthesia guideline for Category 1 caesarean sections, including five-minute multidisciplinary review and conversion to general anaesthesia where appropriate.
Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Create and publish a Category 1 caesarean section and fetal bradycardia process map covering escalation, anaesthetic decisions, effective anaesthesia and delivery timelines.
Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Embed multidisciplinary PROMPT training for anaesthetists, obstetricians and midwives using an evidence-based human-factors approach.
Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Embed simulation-based training using obstetric emergencies, incidents, case reviews and patient experience to improve emergency teamwork and learning.
Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Develop Human Factors and Ergonomics Training Workshops led by a consultant anaesthetist to address systems and behavioural influences on outcomes.
Stated by Airedale NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing records, handovers, ward rounds, SBAR communication and coordinator oversight were relied upon to communicate risk and prioritise inductions.
Stated by Airedale NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North London
Concerns raised1
Lack of liaison between care teams about HbSS-relevant matters before liver biopsy
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.4
Action
Publish advice on biopsy precautions for patients with blood disorders in a peer-reviewed journal within three months.
Stated by British Society Of GastroenterologyStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
Action
Publish advice on biopsy precautions for patients with blood disorders in the BSG newsletter within one month.
Stated by British Society Of GastroenterologyStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
Action
Update the Elective Liver Biopsy SOP to require enhanced risk assessment, specialist MDT discussion, pre-assessment, relevant monitoring, and reference to current professional guidance.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
Action
Disseminate the MDT approach and highlight the updated liver biopsy SOP to referring and booking clinicians through departmental communications and procedure-related emails.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
South Yorkshire (Western)
Concerns raised1
Failure to communicate clinically relevant information between services about epilepsy and psychosis
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.
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
Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 October 2024.
Inner West London
Concerns raised1
Failure of communication between clinical teams and within referrals
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.
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
Reinforce thorough contemporaneous documentation and team communication through resident doctor induction and training.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Formalise written referrals to paediatric gastroenterology in the patient record.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Roll out written referrals with documented outcomes to all specialty consultation requests across the paediatric directorate.
Stated by St George'S University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 July 2025.
Action
Hold monthly Paediatric Gastroenterology Radiology meetings to discuss complex cases and record outcomes in the electronic patient record.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Update the national paediatric gastroenterology service specification to reference second-opinion guidance and strengthen multidisciplinary communication and discussion of unexpected investigation results.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local aspects of Samuel’s care fall outside the national policy and programmes addressed within NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust should respond to concerns about its local management of Samuel’s care and provide further information.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Failure to consult treating consultants across Priory locations
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 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
Send all doctors formal guidance on sharing correspondence when patients receive NHS and private-provider care.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Liaise with Medical Directors of Priory, Elysium and Cygnet to address communication failures collaboratively.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.
Action
Conduct separate service-level Team Incident Reviews involving staff involved in care and consolidate findings at a senior-manager joint meeting for cross-service learning.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The organisation disputes that Consultant-to-Consultant communication failed through its omission, stating it was unaware of the private outpatient appointment.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
