Recurring concern
Unreliable multi-agency communication procedures
- Reports that mention this concern
- 134
- Times this concern has been raised
- 145
- Stated actions linked to this concern
- 303
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 134 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Betsi Cadwaladr University LHB
- Elysium Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Betsi Cadwaladr University LHB
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
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Betsi Cadwaladr University LHB
Monitor compliance with the standard operating procedure through local and divisional Putting Things Right meetings.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Elysium Healthcare Limited
The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
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Concerns raised2
Absence of a protocol or policy for healthcare-prison communication when monitoring sick prisoners on the wing at night
Breakdown in healthcare-prison communication about emergency hospital transfer
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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HM Prison and Probation Service
Implement an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
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HM Prison and Probation Service
Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
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Concerns raised1
Failure of the multi-agency support plan to clearly state limitations on information from unstaffed station attendances
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Poor communication and information sharing between agencies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- One Stockport Health and Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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One Stockport Health and Care Board
Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.
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One Stockport Health and Care Board
Hold a joint learning event involving agencies supporting people with learning disabilities to strengthen information sharing and practice.
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One Stockport Health and Care Board
Agree a joint action plan following the learning event to improve information sharing and practice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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One Stockport Health and Care Board
Pennine Care NHS Foundation Trust cannot directly access patients’ full clinical histories through current systems.
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Concerns raised1
Failure of communication between immigration and sentence-planning agencies
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- HM Prison and Probation Service
- Home Office
- Practice Plus Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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HM Prison and Probation Service
Develop a national Foreign National Offender coordination hub to support the interface between probation and the Home Office.
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HM Prison and Probation Service
Allocate seconded probation practitioners to the Home Office to support frontline practice and resolve escalated interface obstacles.
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Home Office
Continue reviewing potential technological improvements to support timely and secure information exchange with prison officials.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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HM Prison and Probation Service
The Home Office and healthcare provider will respond separately to concerns about foreign national prisoner support and inter-agency communication.
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Practice Plus Group
Practice Plus Group cannot respond directly to improving communication between immigration, sentence-planning and prison agencies because the matter relates to other agencies.
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Concerns raised2
Inadequate communication between mental health care providers and relevant parties
Variation in commissioning-body processes and communication requests
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Dorset Healthcare University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Dorset Healthcare University NHS Foundation Trust
Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
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Dorset Healthcare University NHS Foundation Trust
Implement a live Microsoft Teams handover channel linked to electronic records for documenting bed-flow updates, discussions and decisions.
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Concerns raised1
Failure to communicate concerns about continued unsafe sling use in writing to care agencies
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Bluebird Care (Bromsgrove & Redditch)
- Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Herefordshire and Worcestershire Health and Care NHS Trust
Implement and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Bluebird Care (Bromsgrove & Redditch)
The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
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Concerns raised1
Failure to maintain accurate shared understanding and communication between the D&D Cell and Exeter Air Traffic Control
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record inter-hospital clinical communications
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Leeds Teaching Hospitals NHS Trust
- York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Update and disseminate clinical record-keeping guidance to clinical staff.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Draft and send a patient safety briefing to all staff on documenting clinician communications.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Present the case to surgical colleagues at a Surgical Clinical Governance meeting.
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Leeds Teaching Hospitals NHS Trust
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Leeds Teaching Hospitals NHS Trust
The Trust has no record or recollection of any communication from York Hospital about the deceased’s admission.
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Concerns raised2
Failure to communicate the appropriate level of suicide risk to police
Failure to volunteer the trust's risk grading when reporting a patient to police
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Metropolitan Police Service
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Metropolitan Police Service
Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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NHS England
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026