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.
Birmingham and Solihull
Concerns raised1
Failure to communicate relevant clinical information between hospitals
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.4
Action
Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Action
Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Action
Deliver the agreed cross-Trust action plan to address identified safety concerns.
Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2016.
Action
Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Inner South London
Concerns raised1
Failure of detained organisations to pass risk information consistently between one another
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 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.
Avon
Concerns raised1
Delays in notifying GPs of Crisis Team discharge
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.
West Yorkshire Eastern
Concerns raised1
Breakdown in communication between hospital and prison at discharge
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.1
Action
Create an electronic pathway to share hospital discharge summaries with HMP Leeds.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 10 August 2016.
West Yorkshire (Western)
Concerns raised1
Failure of agencies to obtain information from previously involved agencies
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure of social workers to communicate directly with secure estate staff
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.5
Action
Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.
Stated by Ministry of JusticeStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2015.
Action
Reminded Tower Hamlets’ Director of Children’s Services of social-care expectations and sought assurance about future practice.
Stated by Youth Justice Board for England and WalesStated completedThe respondent said that this action was complete when they made their response on 29 December 2015.
Action
Participate in the London Independent Reviewing Officer Managers Forum project to improve communication and partnership working with the secure estate.
Stated by London Borough of Tower HamletsStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2015.
Action
Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.
Stated by London Borough of Tower HamletsStated plannedThe respondent said that this action was planned when they made their response on 29 December 2015.
Action
Deliver cross-service training for line managers, social workers and Youth Offending Service officers on remand, transition, risk management and secure-estate communication.
Stated by London Borough of Tower HamletsStated completedThe respondent said that this action was complete when they made their response on 29 December 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The reported account of Tower Hamlets communication with the secure estate was inaccurate and contradicted other evidence and national standards.
Stated by Youth Justice Board for England and WalesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Worcestershire
Concerns raised1
Failure of communication during inter-hospital transfers
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2015.
Action
Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Stated by the Royal Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2015.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Inadequate communication about anticoagulation monitoring and potential therapy adjustment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure of agencies to check and share available information before multi-agency meetings
This report raised 15 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
Provide clinical staff attending multi-agency meetings with adequate time to review case information and contribute to discussions and action planning.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2015.
Action
Issue guidance to MAPPA agencies on preparing for meetings and fully recording agreed actions, completed actions and communications.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 May 2015.
Nottinghamshire
Concerns raised1
Lack of clear guidance for communicating patients’ physical condition to GPs
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
