First reported 7 Jan 2014•Latest report 1 Jun 2026
Definition
What this concern includes
Includes failures in provider-to-family or family-to-provider communication where the information concerns patient safety, clinical risks, care plans, deterioration, leave arrangements, incidents, complaints or other matters directly relevant to safe care.
Not included
Excludes communication failures solely between professionals, services or departments when families are not a relevant party.
Excludes generic failures of documentation, staffing, training or policy compliance unless they directly constitute or prevent communication of safety-critical information to or from families.
Excludes routine information provision or dissatisfaction that is not tied to a meaningful public-safety concern.
Excludes communication with patients, students, prisoners or other beneficiaries where families are not materially involved.
Reports
70
Distinct published reports
Individual concerns
74
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
94
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 Care12
NHS England8
Greater Manchester Mental Health NHS Foundation Trust4
Care Quality Commission3
NHS Greater Manchester Integrated Care Board3
Association of Ambulance Chief Executives2
Central and North West London NHS Foundation Trust2
Oxford Health NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
Recipient name withheld2
Somerset NHS Foundation Trust2
South London and Maudsley NHS Foundation Trust2
Sussex Partnership NHS Foundation Trust2
Tameside and Glossop Integrated Care NHS Foundation Trust2
the Dudley Group NHS Foundation Trust2
NHS trust45
Ministerial department12
Healthcare site10
Executive non-departmental public body8
Private limited company7
Integrated care board5
Health and social care service regulator3
Health professional body3
Independent healthcare provider3
Multi-service care provider3
Type not available3
Clinical commissioning group2
Executive agency2
Health-sector membership body2
Health-system partnership2
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.
Essex
Concerns raised1
Failure to respond appropriately to family concerns and communicate the patient’s treatment wishes
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Somerset
Concerns raised1
Failure to clearly document and communicate a patient’s nil by mouth status reported by family on the ward
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.
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
Strengthen documentation, escalation, clinical review, and closed-loop communication of family-raised risks such as nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
Action
Review and standardise bedside safety information, alerts, safety huddles, briefings, and handovers to improve visibility of nil-by-mouth status.
Stated by NHS Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 August 2026.
West London
Concerns raised1
Failure of cascade communication of genetic or hereditary diseases to reach family members who need to know
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.6
Action
Revise the Clinical Genetics service specification.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2026.
Action
Consider how additional Clinical Genetics capacity and infrastructure could be achieved to reduce preventable morbidity and mortality.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Stated by British Society For Genetic MedicineStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Support dissemination of guidance on consent and confidentiality in genomic medicine.
Stated by British Society For Genetic MedicineStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Revise the Clinical Genetics service specification and consider ways to increase capacity and infrastructure for proactive family contact.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Action
Raise awareness of the need to share genetic diagnoses and genomic test results within families.
Stated by British Society For Genetic MedicineStated plannedThe respondent said that this action was planned when they made their response on 27 April 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.10
Position
Genetic or hereditary disease cascade communication falls outside the peer-support charity’s remit.
Stated by Sudden Cardiac Arrest UKOutside remitThe respondent said that this matter was outside its role or authority.
Position
Medical professionals should lead case-by-case cascade communication of genetic or hereditary disease information.
Stated by Sudden Cardiac Arrest UKRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Lack of medical qualifications prevents commenting on initiatives concerning genetic or hereditary disease cascade communication.
Stated by Sudden Cardiac Arrest UKUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The claimed evidence that cascade genetic-risk communication fails to reach more than half of affected family members could not be located.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clinical services lack sufficient capacity and infrastructure to proactively contact lower-risk relatives outside specified high-risk situations.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Implementing service change is outside the organisation’s remit; it can only influence how genetic services are delivered.
Stated by British Society For Genetic MedicineOutside remitThe respondent said that this matter was outside its role or authority.
Position
The evidence supporting the claim that cascade communication fails to reach more than half of affected family members could not be located.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Clinical services lack sufficient capacity and infrastructure to contact lower-risk family members proactively.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NHS England will respond on concerns about recognising agonal breathing or cardiac arrest, defibrillator use, and cascade communication of hereditary conditions.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Limited capacity, variable infrastructure and regulatory restrictions can prevent clinical teams from contacting or testing at-risk relatives directly.
Stated by British Society For Genetic MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Suffolk
Concerns raised1
Ineffective communication processes for patient and family engagement in clinical decisions
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.3
Action
Explore wider rollout of the “write to me rather than about me” approach across the Trust.
Stated by West Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2026.
Action
Operate the Call 4 Concern/Martha’s Rule programme across all inpatient areas, including structured wellness questions and escalation for independent clinical review.
Stated by West Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Action
Extend hospital visiting hours to 8pm to improve relatives’ participation in ward-round communication.
Stated by West Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2026.
Manchester West
Concerns raised1
Failure to communicate family concerns to assessing clinicians
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.
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
Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 February 2026.
Manchester South
Concerns raised1
Ward-round processes failing to facilitate private family disclosure of risk concerns to the multi-disciplinary team
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
Improve MDT ward-round documentation to capture patient and carer views, including mandatory use of the ward-round document.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Pilot a carer questionnaire to inform improvements to the MDT ward-round process.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Roll out the standardised pre-ward-round patient and carer form from pilot sites to all inpatient wards.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Strengthen confidential routes for carers to share risk information outside ward rounds, with documentation in the PARIS carer space.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
Action
Update and distribute information leaflets explaining confidential routes for carers to share concerns.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Update confidentiality policy, staff and carer guidance, and carer-awareness training through the Triangle of Care working group.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 January 2026.
City of London
Concerns raised1
Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
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.
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
Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
County Durham and Darlington
Concerns raised1
Failure to pass on Community Falls Service recommendations to family and social services
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
Work with Community Falls Teams to explore strengthening communication of falls-prevention recommendations to families and social services.
Stated by Durham County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
West London
Concerns raised1
Inadequate information for family and carers on consent, confidentiality and communication when consent is withdrawn
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.
Nottinghamshire
Concerns raised1
Failure to keep family informed about wound deterioration
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.
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
Use a documented Skin Integrity Protocol covering pressure escalation, family updates and duty-of-candour requirements.
Stated by Red Oaks Care HomeStated completedThe respondent said that this action was complete when they made their response on 19 June 2025.
Pin
Get email alerts
Request correction
Includes failures in provider-to-family or family-to-provider communication where the information concerns patient safety, clinical risks, care plans, deterioration, leave arrangements, incidents, complaints or other matters directly relevant to safe care.
