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.
Suffolk
Concerns raised1
Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
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.3
Action
Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
Stated by Suffolk ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Action
Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
Stated by Suffolk ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
Stated by Suffolk County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
Stated by Suffolk ConstabularyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
Stated by Suffolk ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
Stated by Suffolk ConstabularyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
Stated by Suffolk County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
Stated by Suffolk County CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Wiltshire and Swindon
Concerns raised1
Failure of nhs.net email to reliably deliver important information to GP practices
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.4
Action
Use DocMan instead of email for DWF Hub referral-outcome communication with GPs, except when the referrer explicitly requests email.
Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Evaluate the DWF Hub’s DocMan process and use Trust governance processes to decide whether to adopt it across the other Hub teams.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Review AMHT communication practice, identify available changes and assess which options could strengthen controls against GPs missing important communications.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Undertake Clinical Safety Cases, Hazard Logs and Data Protection Impact Assessments before national NHSmail deployment.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust will not change AMHT communication practices until it understands available options, utility and potential consequences.
Stated by Oxford Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The forensic search found that the mental health email was received by the GP practice and copied into the patient's clinical record.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHSmail is considered reliable and resilient, with monitoring, recovery mechanisms, support arrangements and established clinical safety controls.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Yorkshire Eastern
Concerns raised1
Lack of a formal system for communication, information sharing and handover between the respite facility and the Intensive Support Service
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.8
Action
Use a standardised daily handover template to capture clinical information, reviews, tasks, incidents, MDT comments and required follow-up.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Hold a daily Oasis–CRISS huddle to discuss handover information and address immediate actions and queries.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Ensure CRISS shift coordinators bring Oasis handover information to each locality’s daily multidisciplinary team meeting.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Record handover details and required actions in Oasis’s own system.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Add Oasis handover notes, MDT discussions and required actions to LYPFT care records.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Provide training on the handover sheet, including each organisation’s roles and responsibilities.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Monitor handover-process compliance and effectiveness through audits and feedback mechanisms.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Explore Oasis staff access to LYPFT’s electronic patient record and discuss the proposal through the operations meeting.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing referral, admission, joint review, interface, operations and governance processes provide formal communication and risk-management arrangements.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Milton Keynes
Concerns raised1
Failure to communicate concerns that a patient is not medically fit for discharge
This report raised 21 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
Require escalation to emergency-department clinicians, continued emergency-department medical care and liaison-team availability for reassessment when patients cannot engage or remain medically unfit.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Action
Require immediate escalation of concerns to the treating medic or nurse in charge through the Operational Policy.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Action
Implement the Emergency Department adult-discharge SOP defining discharge responsibilities, documentation requirements, safety-netting, and safeguards for higher-risk patients.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Action
Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025.
Action
Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The discharge omissions were considered case-specific, not a systemic issue requiring wider policy or practice change.
Stated by The TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Kent and Medway
Concerns raised1
Failure to establish a communication strategy during critical medical emergencies in custodial settings
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.
Inner North London
Concerns raised1
Lack of communication with the treating mental health team
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
Develop guidance for specialist mental health services covering hospital discharge communication, support needs, risks and unplanned returns to supported accommodation.
Stated by RiversideStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Train and remind staff to communicate behavioural changes, environmental damage, deterioration and other welfare concerns promptly through appropriate clinical escalation channels.
Stated by RiversideStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Support Officers are not authorised or trained to restrain residents because their remit is supportive and non-clinical.
Stated by RiversideOutside remitThe respondent said that this matter was outside its role or authority.
Inner West London
Concerns raised1
Insufficient communication with commissioning authorities and next of kin about care and supervision risks
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.1
Action
Implement communication protocols for promptly and transparently sharing serious care or safeguarding concerns with families and local authorities.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to communicate unsafe visual assessments promptly to the DVLA
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 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
Work with eye healthcare professionals and regulatory bodies to identify and address barriers to notifying the DVLA when disclosure is in the public interest.
Stated by Department for TransportStated plannedThe respondent said that this action was planned when they made their response on 25 April 2025.
Manchester South
Concerns raised1
Failure of CQC participation in multi-agency care home oversight meetings
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 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
Attend multi-agency meetings when concerns about care homes arise.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 16 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
CQC disputes that it rarely attended multi-agency meetings, stating it regularly meets commissioners and attends meetings where concerns exist.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The CQC will address concerns about its attendance at multi-agency care home meetings separately.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of guidelines for communication and information sharing between private psychiatry providers and NHS services providing parallel neurodiversity care
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing hospital discharge guidance already governs information sharing between private and NHS providers, including medication and care information.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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.
