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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to communicate relevant patient information between GP and mental health services
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.6
Action
Implement an assessment service with designated referral administrators who request a Patient Profile from the GP for every Adult Mental Health Services referral.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Send patients and GPs written assessment outcomes describing the formulation and recommendations, with advice and signposting where secondary services are unsuitable.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Use a Community Mental Health Nurse Consultant to liaise with GP practices on assessment services, team responsibilities, information sharing and raising concerns.
Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Work with the National Data Guardian to encourage appropriate information sharing by health and care practitioners.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Written confirmation of assessment outcomes to GPs and ongoing liaison are considered sufficient for communication about referrals.
Stated by Cornwall Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Some information-sharing recommendations were beyond Devon Doctors’ control.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Inadequate communication between healthcare, psychological, psychiatric and prison staff
This report raised 14 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 West
Concerns raised1
Failure to communicate vital transfer information to patients, families and receiving clinicians
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.
South London
Concerns raised1
Failure to communicate guidelines between the local authority and care agency
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.
Derby and Derbyshire
Concerns raised1
Failure to communicate confirmed fractures and necessary care measures to relevant care providers
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.
South Wales Central
Concerns raised1
Fragile communication system between GP, hospital and care home
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.
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.6
Action
Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.
Stated by Healthcare Inspectorate WalesStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2017.
Action
Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.
Stated by Healthcare Inspectorate WalesStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Action
Fast-track medical records for new patients registering at nursing or care homes so doctors receive prior medical history promptly.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to ensure that all relevant personnel are aware of the patient’s mental health observation level
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.3
Action
Update mental health policies and the joint observation protocol to define roles, responsibilities and decision-making case studies.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2017.
Action
Display Emergency Department signage showing the observation process and responsible nursing and special-staff assignments.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Conduct five daily senior-staff situation reports and follow-up reviews covering mental health patients’ risks, observation compliance, care quality and confirmed plans.
Stated by North London NHS Foundation Trust and Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Inner North London
Concerns raised1
Lack of a clearly understood system for communicating concerns and relevant information between the Community District Nurses Team and a community patient’s care provider agency
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.
Gloucestershire
Concerns raised2
Lack of information sharing between agencies providing support services
Failure to identify a lead agency for communication
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
Inadequate communication and liaison between hospital and community care providers after discharge
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.
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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.
