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
Concerns raised1
Failure to transfer important and accurate medical information to telecare and emergency services
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Lincolnshire
Concerns raised1
Failure to ensure CAT Team Leader contact with NHS 111 for increasing unassessed category 3 calls passed to the Trust
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.
Cheshire
Concerns raised1
Lack of multi-agency information sharing and communication between health care providers
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
Support NHS England and devolved health authorities in developing improved mental-health care, including information sharing, case coordination and family-carer support.
Stated by Royal College of General PractitionersStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2019.
Action
Amend assessment and consent forms to ask about psychiatric history and obtain consent to contact relevant mental health practitioners.
Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing RCGP mental-health education, guidance and service-improvement work is considered an adequate response to suicide-prevention concerns.
Stated by Royal College of General PractitionersExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Sussex
Concerns raised1
Insufficient communication and information sharing between prison healthcare organisations
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.3
Action
Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Review providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Action
Improve health and care data collection and information-sharing before, during and after incarceration to support continuity of care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Prison staff cannot access clinical records on SystmOne because such access is not appropriate.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
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
Failure of mental health trusts to communicate placement information with private providers and families
This report raised 10 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.
Lancashire and Blackburn with Darwen
Concerns raised1
Lack of mandated joined-up inter-agency communication at offender release or when new personal relationships develop
This report raised 10 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
Refresh MASH staff messaging periodically on identifying life-licensed perpetrators as high risk and sharing referral information to prompt safeguarding action.
Stated by Lancashire ConstabularyStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Pan-Lancashire MARAC operating protocol already addresses urgent referrals and high-risk prioritisation for relevant offenders.
Stated by Lancashire ConstabularyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Responsibility for referring relevant life-licensed offenders to MARAC lies with the offender manager.
Stated by Lancashire ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing MASH arrangements provide research, information sharing and referral of life-licensed perpetrators to relevant agencies, including Probation and Social Care.
Stated by Lancashire ConstabularyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to follow the procedure for updating CADs about life-threatening deterioration
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.2
Action
Circulate a bulletin reminding staff to create a new CAD for significant patient deterioration and update the LAS.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Include significant-deterioration CAD procedures in initial call-handler training and October personal-development training days.
Stated by Metropolitan Police ServiceStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Manchester North
Concerns raised1
Failure to communicate clinically significant butane gas use and consumption amount to the GP practice
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
Implement a DNA policy requiring discussion of missed appointments and selection of an appropriate patient-contact method.
Stated by Hopwood House Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Use the electronic Butane-misuse code on patients’ problem lists in future.
Stated by Hopwood House Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Identify the EMIS electronic code for flagging butane misuse.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Communicate the butane-misuse EMIS code to all Oldham GP practices as a review lesson.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Complete a wide-ranging review of GP communication across all community substance misuse services.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Change the frequency of communication with GPs across community substance misuse services.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Improve recording of GP communications in the electronic client records system.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.
Stated by Hopwood House Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Norfolk
Concerns raised1
Failure to communicate arranged admission-bed information to ambulance crews
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.3
Action
Work with the CAD supplier to alter call duplication so pertinent destination information transfers into the active call.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
Action
Require dispatch staff to transfer pertinent information manually into new calls until the technological solution is available.
Stated by EEASTStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Share CAD information-recording and transmission best practice and solutions with other ambulance services.
Stated by EEASTStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2019.
North Northumberland
Concerns raised1
Failure to communicate completion of Police investigations to the Local Safeguarding Adults Board and care home owners
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.2
Position
Routine employer updates about criminal investigations are inappropriate and unlawful without the employee’s consent, subject to case-by-case disclosure decisions.
Stated by Northumbria PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Investigation outcomes should normally be communicated directly to the suspect or legal representative by the investigating officer, not through an employer.
Stated by Northumbria PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
