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.
Dorset
Concerns raised1
Lack of shared knowledge and understanding of terminology, processes and communication among emergency and search and rescue services
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.27
Action
Train all incident commanders in the JESIP joint doctrine interoperability framework and its principles of joint working.
Stated by Dorset & Wiltshire Fire and Rescue ServiceStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Represent the Service at the Dorset Blue Light Group meeting to address interoperability challenges involving partners’ different radio communications.
Stated by Dorset & Wiltshire Fire and Rescue ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Hold joint familiarisation briefings for all NPAS and HMCG staff, including communications teams.
Stated by National Police Air ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Consider extending familiarisation briefings to relevant force communications teams and approach the RNLI about equivalent engagement.
Stated by National Police Air ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Develop and distribute a joint quick-action card prioritising establishment of an Emergency Services Airwave channel, with national partners asked to support dissemination.
Stated by National Police Air ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Hold monthly communications meetings between NPAS and HMCG operations-centre leads to debrief notable incidents and assess lessons learned.
Stated by National Police Air ServiceStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Participate in inter-agency debriefs, workshops, capability reviews, training and operational-learning meetings with emergency-service and search-and-rescue partners.
Stated by His Majesty's Coastguard ("HM CoastguardStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Facilitate continuing Dorset Police incident-commander CPD sessions covering Coastguard capabilities, early JRCC contact and coastal staff roles.
Stated by His Majesty's Coastguard ("HM CoastguardStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Provide Joint Rescue Coordination Centre staff with structured visits to police, fire and ambulance control rooms to build understanding of roles, capabilities, processes and communications.
Stated by His Majesty's Coastguard ("HM CoastguardStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Host emergency-service visits to the Joint Rescue Coordination Centre using bespoke presentations and operational-learning content to explain Coastguard roles, capabilities, processes and communications.
Stated by His Majesty's Coastguard ("HM CoastguardStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Collect visit feedback, review objectives and presentation content monthly, adjust materials and communicate identified learning to Joint Rescue Coordination Centre teams.
Stated by His Majesty's Coastguard ("HM CoastguardStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Update the Coastguard Capability Matrix with communications information and publish it on ResilienceDirect for emergency-service partners.
Stated by His Majesty's Coastguard ("HM CoastguardStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Include maritime rescue ‘connect call’ capability in routine exercises with stakeholders and Emergency Services Control Room visits.
Stated by His Majesty's Coastguard ("HM CoastguardStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Hold joint Dorset Police–Coastguard meetings every six months to review working practices and terminology.
Stated by Dorset PoliceStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Engage with Dorset and Wiltshire Fire and Rescue Service to support effective multi-agency communication during incident response.
Stated by National Fire Chiefs CouncilStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Continue encouraging fire and rescue services to follow existing JESIP doctrine and operational guidance.
Stated by National Fire Chiefs CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Continue developing existing operational guidance to make its application more effective.
Stated by National Fire Chiefs CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Update the ResilienceDirect page with RNLI capability information for emergency services and search-and-rescue partners.
Stated by Royal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Prepare materials for direct sharing with emergency-services partners covering RNLI capabilities and limitations, including search equipment and communication capabilities.
Stated by Royal National Lifeboat InstitutionStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Implement JESIP joint-working principles through commander, staff and control-room training, policies and procedures.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Extend JESIP course invitations to HM Coastguard colleagues.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Strengthen SWASFT–HM Coastguard coordination through commander visits and control-room shadowing.
Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Introduce effective aide-mémoires for control-room dispatchers and commanders supporting joint working with HM Coastguard.
Stated by South Western Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Maintain a standard operating procedure for notifying other emergency services and relevant utility providers about incidents.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Implement and routinely exercise a three-way control-room call process enabling direct communication between ambulance, police and fire services during major incidents.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Provide inter-control hailing and multiagency talkgroups enabling direct ambulance, police and fire control-room communication during major or significant incidents.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Maintain a trained NILO cohort with two officers available around the clock to support incident commanders and partner agencies.
Stated by South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
Existing JESIP-based training, assessment and resilience-forum arrangements address communication and interoperability concerns.
Stated by Dorset & Wiltshire Fire and Rescue ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Home Force, rather than NPAS, should open the Emergency Services channel to enable communication between the relevant emergency services.
Stated by National Police Air ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
RNLI and HMCG can communicate using VHF, so RNLI’s lack of Airwave access does not prevent communication by existing arrangements.
Stated by National Police Air ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing JESIP doctrine and NFCC operational guidance provide an appropriate response to interagency communication concerns, so no additional guidance is required.
Stated by National Fire Chiefs CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Lifeboat communications should remain routed through Coastguard tasking; direct contact by other agencies is inappropriate because conflicting messages could distract crews.
Stated by Royal National Lifeboat InstitutionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Search and rescue services are tasked through the Police and do not fall under NHS England’s remit.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised2
Lack of a senior single point of contact for ongoing communications with emergency services across shift changes
Miscommunication between mental health, police and other emergency services
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.7
Action
Appoint a senior single point of contact and provide a prioritised emergency-services line to appropriate senior and out-of-hours managers.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Action
Enable Essex Police to join twice-daily Trust SITREPs with service managers and Matrons to support escalation and communication.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Share learning from the patient-safety incident and Prevention of Future Deaths report at the Essex Crisis Concordat and reinforce communication pathways.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 3 February 2023.
Action
Progress collaborative implementation of the national framework for adults missing from health and care settings through multi-agency planning and a Task and Finish group.
Stated by Essex PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Action
Embed dedicated constable and inspector liaison capacity at the Linden Centre to improve local identification, information sharing, partnership working and strategic oversight.
Stated by Essex PoliceStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
North Yorkshire and York
Concerns raised1
Failure of the HMRC investigator to respond to firearms licensing contact about the concern
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.
West Sussex
Concerns raised1
Ongoing firewall problems between the two Trusts causing reliance on email rather than automatic electronic systems
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
Resolve the inter-Trust firewall problem and establish electronic data connections between the RSFT and SASH E-Tertiary systems.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2022.
Action
Test the E-Tertiary data transfer technically and clinically during the planned oncology patient transfer.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
Manchester South
Concerns raised1
Failure to communicate clearly whether Command and Control has been taken
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.17
Action
Establish and operate a Pursuit Management Working Group to review and redevelop training for pursuit dispatch operators and commanders.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Deliver the devised one-day initial pursuit course to supervisors and operators managing initial-phase pursuits.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Complete design and deliver a four-day tactical-phase commanders’ course to Force Duty Officers and Assistant Force Duty Officers.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Design accreditation, retraining and continuing professional development for personnel involved in pursuit management.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Revise the managing pursuits protocol to clarify command and control responsibilities for pursuits, including cross-border pursuits.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Circulate the revised managing pursuits protocol to all GMP control room staff involved in managing police pursuits.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Revise and clarify the managing pursuits protocol to remove ambiguity about command and control.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Develop and deliver a one-day initial pursuit course for supervisors and operators managing initial-phase pursuits.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Complete design and deliver a four-day tactical-phase commanders’ course for GMP force duty and assistant force duty officers.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Design accreditation, retraining and continuing professional development for pursuit management staff.
Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Action
Circulate the revised managing pursuits protocol to GMP control-room staff involved in managing police pursuits.
Stated by Greater Manchester PoliceStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Deliver command-protocol training for cross-border pursuits and track rollout through bi-monthly governance meetings.
Stated by North West Motorway Patrol GroupStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Revise the managing-pursuits protocol to clarify command-and-control responsibilities.
Stated by North West Motorway Patrol GroupStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Circulate the revised managing-pursuits protocol to all relevant NWMPG control-room staff.
Stated by North West Motorway Patrol GroupStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Deliver command-protocol training for cross-border pursuits and track its rollout through governance meetings.
Stated by North West Motorway Patrol GroupStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Revise the managing-pursuits protocol to clarify command-and-control responsibilities.
Stated by North West Motorway Patrol GroupStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Circulate the revised managing-pursuits protocol to relevant NWMPG control-room staff.
Stated by North West Motorway Patrol GroupStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Command and control remains with the originating authority until an appropriate handover, rather than automatically transferring to NWMPG.
Stated by North West Motorway Patrol GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Delays in sending outpatient letters containing important clinical information
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.
Surrey
Concerns raised1
Lack of requirements for direct discussion between police forces during investigation tasking and transfers
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
Initiate a Task and Finishing Group focused on cross-border missing-person investigations and investigation transfers.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2022.
Action
Develop and circulate draft NPCC advice on requesting missing-person enquiries in another force and transferring investigations for comment before finalisation and wider circulation.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing APP guidance and information-transfer procedures address the concerns about cross-border investigation tasking and transfers.
Stated by National Police Chiefs’ CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings
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.
East Riding and Hull
Concerns raised2
Lack of information sharing between agencies
Unavailability of a shared database for agencies to input common concerns
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Confidential patient information cannot be shared without satisfying data protection law, public interest requirements and the Common Law Duty of Confidentiality case by case.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Home Office and Department of Health and Social Care hold responsibility for the majority of concerns and lead related recommendations.
Stated by Ministry of JusticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Lack of central points of contact for inter-agency referrals and information sharing
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.4
Action
Establish and operate a central Probation point-of-contact email for inter-agency information sharing.
Stated by Probation Young Adults Central Team BirminghamStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Raise partner-agency awareness of the central point of contact to facilitate ongoing information sharing.
Stated by Probation Young Adults Central Team BirminghamStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Grant CGL licences to access important clinical patient details.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Action
Include alternative contact details in out-of-office messages when named professionals are unavailable.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing named workers, duty workers and out-of-office arrangements provide central points of contact for information sharing and crisis queries.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
CGL disputes that it lacks a central contact or accepts only GP referrals, citing established contacts and referrals from multiple agencies.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust and Change, Grow, LiveDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
