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.
Inner South London
Concerns raised1
Failure to communicate patient risk and vulnerability to relevant agencies
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Inadequate communications between the London Ambulance Service and neighbouring ambulance services
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of formal communication and information-transfer protocols between healthcare establishments
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual NHS Trusts are responsible for developing transfer protocols with private-sector providers, reflecting provider variation and patient factors.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Staffordshire South
Concerns raised1
Failure to ensure effective communication of discharge information to GPs at practices outside the Stoke on Trent area
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
Switch on electronic discharge correspondence for GP practices in Stone, including the deceased’s practice.
Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.
Action
Switch on electronic discharge correspondence for remaining Stafford and Cannock GP practices by the end of July 2014.
Stated by University Hospitals of North Midlands NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Develop a supplier solution enabling electronic discharge correspondence for GP practices beyond Stoke and North Staffordshire.
Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 April 2014.
Action
Continue negotiating annual funding arrangements with external GP practices and request confirmation of payment for electronic correspondence.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Delivery of discharge-information improvements is a shared responsibility involving the Local Health Economy IM&T Group and Clinical Commissioning Groups.
Stated by University Hospitals of North Midlands NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Ongoing electronic correspondence costs are expected to be funded by GP practices or their local Clinical Commissioning Groups.
Stated by University Hospitals of North Midlands NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Electronic rollout beyond existing areas cannot be completed until participating areas confirm funding for annual practice charges.
Stated by University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Wiltshire and Swindon
Concerns raised1
Failure of the communication pathway for engaging mental health professionals to be clear and effective
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.2
Action
Review the mental health referral process and current staff training provision, identifying resulting actions in collaboration with AWP.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 April 2014.
Action
Include community crisis-intervention access information in the patient leaflet, Mental Health Act training programme and Trust intranet.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 April 2014.
Leicester City and South Leicestershire
Concerns raised1
Failure to exchange prescription information between treatment services and the GP
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
Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 March 2014.
Action
Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 March 2014.
Action
Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 March 2014.
Action
Audit case notes for GP correspondence within 14 days and repeat the audit every six months.
Stated by Leicestershire Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 March 2014.
Inner West London
Concerns raised1
Failures in communication between local services and out-of-area psychiatric care providers
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
York City
Concerns raised1
Insufficient police communication of detailed information during river rescues
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.
Berkshire
Concerns raised1
Lack of a procedure for transferring patient information between different Trusts
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Delays and limitations in liaison and communication between prison and hospital health care staff
This report raised 11 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.
Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.
Position
The National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.
Stated by Department of Health and Social CareRedirects 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.
