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
Failure to ensure communication between interventional radiology and hepatology specialists
This report raised 5 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
Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
Stated by Barts Health 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
Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to share and escalate delayed antibiotic treatment information
This report raised 10 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 communication between hospital departments about responsibility for patient 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.3
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Action
Agree the renal admission pathway with advice clarifying the reason for referral.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Amend Trust Internal Professional Standards to reduce failures caused by misunderstanding between departments.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Escalate and document patients requiring specialty care through Emergency Department huddles and the Huddle Log.
Stated by University Hospitals of North Midlands 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 absence of consultant review was not a separate error because existing senior-review mechanisms were robust; it resulted from misunderstanding responsibility for the patient.
Stated by University Hospitals of North Midlands NHS Trust
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Concerns raised1
Failure to seek clarification of unclear prescribing advice
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
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication 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.
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 directly inform senior clinical staff of disclosed suicide risk
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.3
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Action
Review current training and support for recognising risk, escalating concerns and safeguarding adults.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Run a two-day professional leadership forum to reinforce individual responsibility and accountability for patient safety and suicide prevention, with learning cascaded to teams.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Issue a safeguarding newsletter reminder about procedures following disclosures of possible suicidal intent, including the suicide-support leaflet.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing training, policies, safeguarding support and mental health provision are considered sufficient to ensure staff recognise and escalate suicide risks.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Position
The incident is considered isolated, and staff are considered aware of their safeguarding obligations and required actions.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised1
Failure of clear communication between clinicians and nursing staff
This report raised 9 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
Implement a CDU pathway document to support communication between the main hospital department and CDU on admission.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised2
Failure to communicate deterioration between ward doctors and nursing staff
Failure of consultants to communicate about patients with ward 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.1
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Action
Addressed orthopaedic NEWS-policy noncompliance through staff discussions and circulated responsibilities for recording and escalation.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to formally record and communicate important messages between staff members
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
Issue an internal alert directing inpatient wards to reflect on how information from different sources is received and captured.
Stated by Norfolk and Suffolk NHS Foundation 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
No single evidence-based communication tool can currently be implemented to eliminate the risk of important information failing to reach ward rounds.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to communicate accurate overdose information to liaison psychiatry
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
Remind staff through Clinical Board quality, safety and experience structures to take complete, diligent mental-health histories using all available information.
Stated by Cardiff & Vale University LHB
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 documentation error stating two tablets were taken did not influence the clinical decision because clinicians knew twenty tablets had been taken.
Stated by Cardiff & Vale University LHB
Data last updated 7 September 2026