Recurring concern

Unreliable multi-agency communication procedures

First to latest report 29 May 2013 — 16 Jun 2026

Reports that mention this concern: 134
Times this concern has been raised: 145
Stated actions linked to this concern: 303

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Reports and published responses 134 reports

See individual reports that have raised this concern, and the actions taken in response

19 Dec2013
Central and South East Kent
Concerns raised1
1. Failure of effective oral and written communication between integrated care and district nursing services
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michael Longley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of effective oral and written communication between integrated care and district nursing services
Wider context from the report
“I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place. ”
Source location
Michael Longley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
28 Nov2013
Milton Keynes
Concerns raised1
1. Lack of an effective communication system between GP surgeries and district nurses
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Doris Phoebe Miller · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of an effective communication system between GP surgeries and district nurses
Wider context from the report
“(2) On the 23rd July 2013 the GP had requested the district nurses to attend Mrs Miller to carry out an urgent blood test. The GP was dismayed to discover a week later that the call out sample had not been taken and that the results, therefore, were not available to her. There appears to be no system for effective communication between the GP surgery and the district nurses. Again this gives rise to a concern that lives may be at risk. ”
Source location
Doris Phoebe Miller · Prevention of Future Deaths report
Page 1 · concerns
Open source report
1 Oct2013
Oxfordshire
Concerns raised1
1. Delays in communication between police and the ambulance control room
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

DAVID LESLIE SELMAN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David Leslie Selman, who had schizophrenia and epilepsy, died after consuming a large amount of legal highs that adversely reacted with his prescription drugs. When he developed unusual behaviour, shaking and spasms at a public house, ambulance attendance was delayed by a miscommunication about whether the crew should stand down or stand back, and information about his condition was not passed on for reassessment of the resources needed. He later went into cardiac arrest before arriving at hospital and could not be revived; the inquest recorded multiple drug toxicity as the medical cause of death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in communication between police and the ambulance control room
Wider context from the report
“5.1 There was a miscommunication, or misunderstanding, between the control room and the ambulance staff as regards to whether they were required to stand down or stand back. 5.2 If they had stood back as instructed then I understand they would have been only a matter of two to three minutes away from the scene as opposed to ten to twelve minutes. In addition to the slight delays in communication between the police and the ambulance control room, this exacerbated a problem. ”
Source location
DAVID LESLIE SELMAN · Prevention of Future Deaths report
Page 3 · concerns
Open source report
29 May2013
Worcestershire
Concerns raised2
1. Inadequate communication between agencies
2. Failure to share interagency serious incident reviews
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

Worcestershire Safeguarding Children Board
Stated actions 1
1. Worcestershire Safeguarding Children Board
  Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.
Respondent positions 1
1. Worcestershire Safeguarding Children Board
  Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.
  Existing arrangements considered sufficient
AI-generated summary

Dana Louise Baker · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Dana Louise Baker was a looked after child whose foster placement broke down, after which she stayed with an adult friend and the following day hanged herself in a public place. The principal concerns were inadequate knowledge, understanding and communication between agencies, and the confidential handling of Individual Management Reviews, which prevented agencies from understanding areas of mutual concern.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate communication between agencies
Wider context from the report
“(1) As outlined in the IMR's, the Serious Case Review and the draft Overview Report there was a lack of knowledge and understanding as between various agencies involved with Dana and inadequate communication between them. ”
Source location
Dana Louise Baker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share interagency serious incident reviews
Wider context from the report
“(2) The IMR's are kept confidential and not even shared as between Agencies concerned. Some IMR authors indicated that they could not comment on areas of "mutual concern" because they were unaware of the content of other Agency's IMR's. ”
Source location
Dana Louise Baker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.

Verbatim wording from the response
“The sharing of IMRs between agencies on the Panel has always been a key element of the SCR process and the more collaborative 'systems approach'”

Source location
2014-0242-Response-by-Safeguarding-Children-Board
Page 2 · response
Published 29 May 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.

Verbatim wording from the response
“I would suggest that the current government guidance contained in Working Together to Safeguard Children 2013, together with the knowledge that Worcestershire Safeguarding Children Board has fully embraced this guidance, would help to address the issue of the sharing of IMRs which you have raised in the Regulation Report. Government guidance has been developed in the time since EW's death and WSCB has responded positively to this change.”

Source location
2014-0242-Response-by-Safeguarding-Children-Board
Page 2 · response
Published 29 May 2014
Open published response