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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to achieve clear communication of key information with other agencies involved in 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 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
Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.
Stated by Pembroke Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Position
Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Stated by NHS Devon Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Inter-Trust communication channels failing between geographically proximate NHS Trusts
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.
West Yorkshire (Western)
Concerns raised1
Failure to maintain communication between the college and external mental health support organisations
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
Discuss multi-agency safeguarding communication with the NHS South West Yorkshire Partnership Foundation Trust.
Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Review and amend procedures for contacting external safeguarding agencies, including obtaining updates under Welfare Plans and during permanent exclusion.
Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Remind external agencies of their safeguarding information-sharing responsibilities under applicable national guidance.
Stated by The Duchess of Somerset’s HospitalStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Implementing multi-agency communication changes is outside the College’s authority and requires discussion at a higher level.
Stated by The Duchess of Somerset’s HospitalOutside remitThe respondent said that this matter was outside its role or authority.
Position
The NHS Trust responsible for CAMHS services is responsible for setting out steps to improve local information-sharing.
Stated by The Duchess of Somerset’s HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to seek clarification and communicate effectively with medical colleagues about fluctuating or lacking capacity
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
Require officers to obtain, record and share treating-clinician rationale when partner risk assessments differ, with learning fed into relevant working groups.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 1 November 2024.
East London
Concerns raised1
Failure to leave or share written fire risk management plans with relevant recipients
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
Review information-sharing processes, the data-protection impact assessment and third-party disclosure arrangements, consulting information-management specialists and the Information Commissioner.
Stated by London Fire BrigadeStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policy authorises sharing advice only with a resident who can understand and retain it, so staff followed the correct process.
Stated by London Fire BrigadeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Liverpool and the Wirral
Concerns raised1
Failure to communicate the limits of responders' diagnostic ability to ambulance services
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.
Manchester North
Concerns raised1
Failure of consultant-to-consultant communication across NHS and private care
This report raised 13 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
Send all doctors formal guidance on sharing correspondence when patients receive NHS and private-provider care.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Liaise with Medical Directors of Priory, Elysium and Cygnet to address communication failures collaboratively.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 August 2024.
Action
Provide five Band 7 Out of Area Practitioners to monitor private out-of-area placements, coordinate providers and support discharge planning.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Remind clinicians to obtain and consider patients’ background history and involvement of other services at admission.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Action
Disseminate guidance on identifying and liaising with external care providers through network meetings, circulated minutes and a learning cascade.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 12 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The organisation disputes that Consultant-to-Consultant communication failed through its omission, stating it was unaware of the private outpatient appointment.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The doctor who sees the patient, rather than the GP, is responsible for sharing clinic correspondence with other care providers.
Stated by Pennine Care NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South London
Concerns raised1
Failures in communication during welfare-check responses
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
Deliver learning to MPS staff and officers on district location sharing and compliance with relevant standard operating procedures.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 7 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The records do not show a communication failure between Surrey Police and the Metropolitan Police Service; both calls were handled correctly.
Stated by Surrey PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing procedures for transferring calls to other police forces were followed appropriately and ensured timely information transfer.
Stated by Surrey PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
No communication failure between Surrey Police and the Metropolitan Police occurred because no record of a relevant 4 January call exists.
Stated by Metropolitan Police ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised3
Failure to communicate the RCRP challenge process to BSMHFT
Delays in communicating police disagreement with the reported risk category
Failure to inform BSMHFT when missing patient investigations are closed
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 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
Circulate the RCRP escalation process to responsible clinicians, senior nurses and clinical staff, including its incorporation in the updated policy.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Continue updating and circulating the escalation process when contact details change.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Maintain and disseminate the partner escalation process, including direct access to the Force Duty Manager for decision reviews.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Require police to notify the Trust in writing of decisions and reasoning when not deploying immediately after critical concern is communicated.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Stated by West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Missing Persons is outside Right Care Right Person, so existing police procedures for police involvement should continue.
Stated by Home OfficeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The APCC cannot mandate its members to undertake actions in response to the identified safety concerns.
Stated by Association of Police and Crime CommissionersOutside remitThe respondent said that this matter was outside its role or authority.
Position
Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.
Stated by Association of Police and Crime CommissionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Stated by National Police Chiefs’ CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised1
Failure to communicate relevant clinical information before transfer
This report raised 12 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
Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
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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.
