First reported 29 May 2013•Latest report 16 Jun 2026
Definition
What this concern includes
Includes failures of explicitly multi-agency communication procedures that impair the timely, accurate and complete exchange of safety-relevant information between involved agencies, including the anchor's prison-services communication failure.
Not included
Excludes generic communication, training, staffing or coordination deficiencies where no explicitly multi-agency communication procedure is identified.
Excludes failures confined to a single organisation's internal communication process.
Excludes failures of a separately named pathway, system or hazard when that concern provides the more specific supported boundary.
Excludes neutral descriptions of multi-agency working without an identified unsafe communication condition.
Reports
134
Distinct published reports
Individual concerns
145
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
303
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 England17
Ministry of Justice14
HM Prison and Probation Service10
Home Office8
Recipient name withheld6
Metropolitan Police Service5
Association of Ambulance Chief Executives4
East London NHS Foundation Trust4
National Police Chiefs’ Council4
Care Quality Commission3
College of Policing3
Greater Manchester Mental Health NHS Foundation Trust3
Greater Manchester Police3
NHS Greater Manchester Integrated Care Board3
NHS trust58
Ministerial department29
Police force22
Healthcare site20
Executive non-departmental public body18
Private limited company14
Type not available14
Executive agency11
Integrated care board8
English county council7
Prison or young offender institution7
National policing body5
Registered provider of social housing5
Fire and rescue service4
Health-sector membership body4
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.
West Sussex, Brighton and Hove
Concerns raised1
Lack of awareness of available careline technology for direct patient contact and emergency-service conferencing
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.6
Action
Review use of Careline functionality during initial 999 calls to improve communication pathways and maximise available technology.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Develop closer partnership working with Careline providers through the Falls and Frailty Pathways of Care.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Monitor relevant call-handling and note-taking technologies and consider their use where they can demonstrably improve outcomes.
Stated by Appello Careline LimitedStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Share and discuss the PFD learning with the ambulance service medical directors group.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Recommend that each ambulance service review local procedures for handling calls from telecare providers and assess three-way calling availability.
Stated by Association of Ambulance Chief ExecutivesStated completedThe respondent said that this action was complete when they made their response on 14 August 2026.
Action
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
Stated by TSAStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The organisation cannot mandate or instruct ambulance services, whose local procedures and implementation decisions remain their responsibility.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Position
Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South Yorkshire (Western)
Concerns raised1
Lack of communication and engagement between agencies involved in Ollie’s care
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.32
Action
Introduce named Targeted Early Help link workers and structured consultation routes for every Barnsley school.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Strengthen Early Help–CAMHS coordination through direct contact, improved referrals, timely information sharing and joint planning.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Require multi-agency information gathering and triangulation through updated practice standards and case-management guidance.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Use supervision, case tracking and quality assurance audits to verify multi-agency contact, recording, role clarity and progression of actions.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Train Targeted Early Help and Children’s Social Care staff in multi-agency working, information sharing, professional curiosity and contextual safeguarding.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Implement the preventative, conversational Integrated Front Door model through phased test-and-learn activity, with operation planned by March 2027.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Complete local actions addressing information sharing and multi-agency discharge planning.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Provide Barnsley CAMHS training on information sharing and multi-agency working.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Train Targeted Early Help practitioners on CAMHS referrals and access to children’s mental health support.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Provide annual Targeted Early Help training, with additional sessions arranged at social care’s request.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Meet with Targeted Early Help senior management to explore improved joint working and timely information sharing.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Establish daily Targeted Early Help attendance at the Branching Minds briefing.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Establish fortnightly CAMHS and Targeted Early Help case review meetings for coordinated working.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Hold bi-monthly strategic reviews of CAMHS and Targeted Early Help joint working and consider developing a Memorandum of Understanding.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Consider a collaborative Trust and partner-agency response to the Act’s information-sharing provisions.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2026.
Action
Introduce named Targeted Early Help link workers for every Barnsley school and structured consultation opportunities for school staff.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Strengthen Early Help–CAMHS coordination through clearer referral, information-sharing and joint-planning pathways.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Require practitioners to gather and triangulate information from education, health and other professional partners through updated practice standards.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Use management supervision to check partner contact, follow-up, recording and progression of communication actions.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Deliver multi-agency working, information-sharing, professional-curiosity and contextual-safeguarding training for Targeted Early Help and Children’s Social Care staff.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Implement updated Multi-Agency Safeguarding Arrangements defining cross-agency information-sharing, accountability, escalation and professional challenge.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Require direct contact, role clarification, recorded outcomes and ongoing coordination when children are involved with Targeted Early Help and CAMHS.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Invite CAMHS practitioners to relevant family, safeguarding and professional meetings, with follow-up and escalation when participation does not occur.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Audit multi-agency contact, role clarity and recorded communication, feeding gaps into management oversight, supervision and team learning.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Implement a conversational Integrated Front Door through phased 2026/27 test-and-learn activity, with operation planned by March 2027.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Introduce CAMHS co-location within the Integrated Front Door during 2026–2027.
Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated plannedThe respondent said that this action was planned when they made their response on 17 July 2026.
Action
Adapt escalation protocols so the school contacts the crisis team directly when students self-harm or may harm themselves.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Use CPOMS profile pinning to identify agencies involved with students and improve communication oversight.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Train safeguarding colleagues to routinely share relevant information with all agencies involved in multi-agency support.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Train seven additional staff in Early Help processes and use an Early Help Practitioner as the school liaison.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Hold termly Compass Be liaison meetings focused on next steps for identified students with mental health concerns.
Stated by Barnsley AcademyStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Barnsley Metropolitan Borough Council is the lead agency for the wider Barnsley Children’s Reform Agenda response.
Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Failure to ensure clear communication with GP services about ongoing drug use and doses
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Cumbria
Concerns raised1
Failure to pass full and accurate information between NWAS and CHOC
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
Stated by North West Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Derby and Derbyshire
Concerns raised1
Lack of connectivity and information sharing between services
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.
Inner North London
Concerns raised1
Failure to provide the transport vehicle location to emergency services
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 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.
Suffolk
Concerns raised1
Failure to provide Probation Services with timely release information
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.1
Action
Compile a telephone list of active contact numbers for each Probation Area in England and Wales.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The release licence clearly instructed the prisoner when and where to report, and Durham Probation received timely release information at its correct email address.
Stated by HM Prison and Probation ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Northamptonshire
Concerns raised1
Failure to communicate medication changes between private and NHS psychiatric providers
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.
East London
Concerns raised1
Breakdown of communication about responsibility for penicillin prescription and dispensation
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Proactively contact patients with sickle cell disease annually for medication reviews, including Penicillin V prescribing and compliance.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Liaise directly with secondary or tertiary specialists when responsibility for Penicillin V prescribing or dispensing requires clarification.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Move all patients with sickle cell disease to electronic repeat dispensing for Penicillin antibiotics.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Require the on-site pharmacist to communicate uncollected sickle cell disease prescriptions to the practice.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Increase access to shared care records to improve communication between primary and secondary care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Develop greater interoperability of electronic patient records, starting with structured medication information sharing.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the prophylactic penicillin communication concern lies with other bodies.
Stated by Partnership of East London Co-operatives LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without a shared care protocol, the hospital should retain responsibility for care, monitoring and issuing the prescription.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Lack of shared policies, guidance and understanding about information relevant for sharing between services
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.7
Action
Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Develop and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Add contextual-information-sharing guidance to the electronic referral document for professionals.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Practice does not consider a policy or guidance on relevant information sharing capable of assisting with this concern.
Stated by Sett Valley Medical CentreNo action considered necessaryThe respondent said that no further action was needed.
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Includes failures of explicitly multi-agency communication procedures that impair the timely, accurate and complete exchange of safety-relevant information between involved agencies, including the anchor's prison-services communication failure.
