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.
North East Kent
Concerns raised1
Lack of a policy governing communication between KMPT and the Kent County Council AMHP service to ensure timely Mental Health Act applications
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.
North East Kent
Concerns raised1
Inadequate timely communication and follow-up action between agencies
This report raised 8 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
Work with the Children’s Commissioner’s Office and Information Commissioner’s Office to identify ways to improve data sharing in child safeguarding cases.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2022.
Action
Invest in new strategic leadership posts to improve inter-agency dialogue and provide rapid escalation and resolution.
Stated by Kent and Medway Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 17 March 2022.
Action
Develop and implement shared Kent and Medway escalation policies and protocols for complex, high-risk children and young people.
Stated by Kent and Medway Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 17 March 2022.
Action
Create joint posts across local authority and primary care to identify children with additional needs early and coordinate care rapidly.
Stated by Kent and Medway Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 17 March 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Kent local authority is responsible for undertaking assessments and providing services for children in need, including disabled children.
Stated by Department for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Lack of a multi-agency information-sharing framework for assessing and managing risk during Home Detention Curfew release
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.1
Action
Amend the HDC Policy Framework to require necessary multi-agency information sharing before release decisions.
Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 20 January 2022.
Greater Manchester South
Concerns raised1
Failure to communicate the planned pre-41-week induction pathway
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.
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
Action
Establish a uniform, interoperable format for maternity records across clinical systems.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 7 January 2022.
Lancashire and Blackburn with Darwen
Concerns raised1
Inadequate communication between healthcare personnel at medical emergency scenes and prison or ambulance control
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.6
Action
Liaise with NWAS to define clinician training needs and incorporate ambulance-control communication guidance into the HMP Lancaster Farms emergency-response procedure.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Conduct joint prison-healthcare debriefs after incidents to identify communication lessons involving healthcare, the communications department and NWAS.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Implement a dedicated radio net enabling clinicians and the prison communications room to communicate directly and relay information securely during medical emergencies.
Stated by SpectrumStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Monitor the new emergency-communication system through staff feedback, healthcare incident reviews and safety-huddle and organisational learning.
Stated by SpectrumStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.
Action
Use a dedicated radio channel to connect clinicians directly with ambulance services through the communications room during medical emergencies.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 16 December 2021.
Action
Restrict access to the emergency radio network to the communications room, healthcare staff and first responders on scene.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 16 December 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Using the wing phone could delay emergency communication and leave the patient without a nurse while the clinician makes the call.
Stated by SpectrumUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
A mobile phone was not a reliable communication solution because phone signal at HMP Lancaster Farms was unreliable.
Stated by SpectrumUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Wales Central
Concerns raised1
Lack of a direct communication method between ambulance service call centre staff and prison staff providing basic life support
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
Devise a Local Operating Protocol governing direct communication between prison staff providing basic life support and the Welsh Ambulance Service.
Stated by Cardiff PrisonStated completedThe respondent said that this action was complete when they made their response on 22 November 2021.
Action
Pilot mobile phones carried by the Orderly Officer and Night Orderly Officer to enable direct communication with the Welsh Ambulance Service during emergencies.
Stated by Cardiff PrisonStated plannedThe respondent said that this action was planned when they made their response on 22 November 2021.
Inner North London
Concerns raised1
Failure to communicate safety-critical mental-health and medical information to relevant 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 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.
London City
Concerns raised1
Failure to communicate between offender managers and event organisers before extremist offenders attend events
This report raised 23 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.5
Action
Write to accountable officers of registered English higher education providers, sharing the coroner’s report and asking them to consider risk assessment and external-venue information-sharing changes.
Stated by Office for StudentsStated plannedThe respondent said that this action was planned when they made their response on 3 November 2021.
Action
Fund and deploy specially trained CT Nominal Management officers, with accountable senior regional roles for terrorist-risk offender management.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Action
Engage higher education colleagues to encourage effective communications between event organisers and host venues for high-risk events.
Stated by Department for EducationStated plannedThe respondent said that this action was planned when they made their response on 3 November 2021.
Action
Engage Office for Students colleagues to encourage higher education providers to consider event-organiser and host-venue communications in risk-management procedures.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Action
Revise MAPPA guidance to require consideration of disclosure to relevant event hosts and clearer recording of disclosure decisions.
Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 3 November 2021.
Inner South London
Concerns raised1
Lack of a procedure for responding to threats and passing information to other authorities
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.
Norfolk
Concerns raised1
Failure to provide timely responses to care staff seeking clarification of discharge and escalation plans
This report raised 19 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.1
Action
Provide community clinicians access to hospital correspondence, including discharge letters, through the ICE electronic results system.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 23 July 2021.
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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.
