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 clearly record treatment plans between transferring and receiving clinical staff
Failure to agree treatment plans between transferring and receiving clinical staff
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
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust -
Action
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals 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
The existing Treatment Escalation Plan adequately specified escalation to acute hospital if deterioration occurred, despite omission from the handover form.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure to communicate all relevant patient information to doctors dosing warfarin
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.2
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Action
Re-emphasised clear anticoagulation communication, shared case learning with clinical leaders and forums, and delivered repeated daily-brief reminders to clinical teams.
Stated by University Hospitals of Leicester NHS Trust -
Action
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
Stated by University Hospitals of Leicester NHS Trust
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Concerns raised1
Lack of clear guidance for communication of test results and patient presentation across specialisms and team roles
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 provide staff with clear information about food and fluid refusal duration and warning signs
This report raised 12 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
Establish and train staff on a joint food and fluid refusal policy at HMP Cardiff.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Persisting relationship and communication problems between maternity and neonatal 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.4
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Action
Run the Culture and Civility improvement project and track its action plan through programme governance.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust -
Action
Publish and socialise the Culture and Civility workshop outputs and charter.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust -
Action
Expand Team of the Shift huddles to include neonatal team members.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust
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Action
Implement a midwife-led junior doctor induction session on roles, relationships and supportive teamwork.
Stated by University Hospitals of Derby and Burton NHS Foundation Trust
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Concerns raised1
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
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.5
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Action
Communicate the coroner’s concerns and effective communication requirements to all staff.
Stated by Stockton Care Limited -
Action
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
Stated by Stockton Care Limited -
Action
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
Stated by Stockton Care Limited
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Action
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
Stated by Stockton Care Limited -
Action
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
Stated by Stockton Care Limited
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Concerns raised1
Failure of the bleep system to convey information electronically
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
Upgrade critical messaging services at Ysbyty Glan Clwyd and Wrexham Maelor Hospital.
Stated by Betsi Cadwaladr University LHB -
Action
Replace Ysbyty Gwynedd’s on-site paging with an integrated critical messaging service.
Stated by Betsi Cadwaladr University LHB -
Action
Test WiFi telephones and smartphone messaging applications with frontline clinicians to assess future communication options.
Stated by Betsi Cadwaladr University LHB
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Action
Decide the specific future communication solution using the results of technical testing with frontline clinicians.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Lack of a clear system for communication between teams about patient progress and missed appointments
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.2
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Action
Develop a standard operating procedure for monitoring potentially cancerous lesions, including information transfer between teams.
Stated by Worcestershire Acute Hospitals NHS Trust -
Action
Develop a clear process for handing patients from Cancer Services to departmental teams when they leave active cancer tracking.
Stated by Worcestershire Acute Hospitals NHS Trust
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Concerns raised1
Failure to share key patient information between clinicians and the nursing team
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Breakdowns in communication between inpatient staff and the CMHT
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.
Data last updated 7 September 2026