Recurring concern
Unreliable multi-agency communication procedures
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Request correctionFirst reported 29 May 2013•Latest report 16 Jun 2026
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
- Individual concerns
- 145
- Date range
- 2013–2026
- Stated actions
- 303
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Stated by Betsi Cadwaladr University LHB -
Action
Monitor compliance with the standard operating procedure through local and divisional Putting Things Right meetings.
Stated by Betsi Cadwaladr University LHB
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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Position
The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
Stated by Elysium Healthcare Limited
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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.
Responses linked to these concernsEach 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
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Action
Implement an agreed system clarifying prison welfare checks, healthcare clinical observations, required check levels and clinically appropriate inpatient transfers.
Stated by HM Prison and Probation Service -
Action
Share the escort-review findings with healthcare staff to improve communication and clarify urgency during hospital escorts.
Stated by HM Prison and Probation Service
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Introduce peer discussions so managers oversee individual social-care assessments and reviews and strengthen social-work practice.
Stated by One Stockport Health and Care Board -
Action
Hold a joint learning event involving agencies supporting people with learning disabilities to strengthen information sharing and practice.
Stated by One Stockport Health and Care Board -
Action
Agree a joint action plan following the learning event to improve information sharing and practice.
Stated by One Stockport Health and Care Board
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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Position
Pennine Care NHS Foundation Trust cannot directly access patients’ full clinical histories through current systems.
Stated by One Stockport Health and Care Board
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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.
Responses linked to these concernsEach 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
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Action
Develop a national Foreign National Offender coordination hub to support the interface between probation and the Home Office.
Stated by HM Prison and Probation Service -
Action
Allocate seconded probation practitioners to the Home Office to support frontline practice and resolve escalated interface obstacles.
Stated by HM Prison and Probation Service -
Action
Continue reviewing potential technological improvements to support timely and secure information exchange with prison officials.
Stated by Home Office
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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Position
The Home Office and healthcare provider will respond separately to concerns about foreign national prisoner support and inter-agency communication.
Stated by HM Prison and Probation Service
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Position
Practice Plus Group cannot respond directly to improving communication between immigration, sentence-planning and prison agencies because the matter relates to other agencies.
Stated by Practice Plus Group
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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.
Responses linked to these concernsEach 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
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Action
Implement an out-of-area inpatient-care procedure requiring regular contact and documentation with patients, families, carers and treating clinicians.
Stated by Dorset Healthcare University NHS Foundation Trust -
Action
Implement a live Microsoft Teams handover channel linked to electronic records for documenting bed-flow updates, discussions and decisions.
Stated by Dorset Healthcare University NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Implement and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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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Position
The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
Stated by Bluebird Care (Bromsgrove & Redditch)
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Update and disseminate clinical record-keeping guidance to clinical staff.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Draft and send a patient safety briefing to all staff on documenting clinician communications.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Present the case to surgical colleagues at a Surgical Clinical Governance meeting.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Action
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Stated by Leeds Teaching Hospitals NHS Trust
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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Position
The Trust has no record or recollection of any communication from York Hospital about the deceased’s admission.
Stated by Leeds Teaching Hospitals NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Implement the Right Care, Right Person approach with health partners, aligning policies, terminology and information requirements for risk assessment and police support.
Stated by Metropolitan Police Service
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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Position
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS England
Data last updated 7 September 2026