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.
Manchester South
Concerns raised1
Failure of GP consultation arrangements to support effective communication about deteriorating health
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.4
Action
Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
Action
Discuss negative patient feedback with relevant practices to support learning and improvement.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 26 August 2021.
Action
Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 August 2021.
Action
Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 August 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
National general practice guidance required remote triage and face-to-face appointments where clinically appropriate, addressing concerns about remote-only care.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The CCG cannot determine how GP consultations are undertaken because it lacks legal powers and is not party to the nationally negotiated contract.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing guidance, procedures and resources are considered sufficient to support safe remote general practice consultations alongside face-to-face appointments.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to clearly convey community management advice and risks to community health professionals and families
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.1
Action
Communicate appropriate advice and guidance to relevant providers to increase staff awareness of available materials.
Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 26 August 2021.
Liverpool and the Wirral
Concerns raised1
Failure to communicate treatment plans and condition-related risks to patients and confirm their understanding
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.4
Action
Re-emphasise communication with families and documentation of discussions through clinical-team meetings and regular communications, including providing relevant letters.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Audit communication documentation and the quality of recorded clinical information through a routine audit cycle.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Action
Develop standardised communication and referral processes with Alder Hey and the wider paediatric network, particularly for shared-care arrangements.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Amend paediatric staff induction to cover communication with families, communication with other organisations, and responses when children are not brought to appointments.
Stated by Mersey and West Lancashire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Essex
Concerns raised1
Deficiencies in training and procedures for communication with the family
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.
Gwent
Concerns raised1
Failure to advise callers of the expected emergency ambulance arrival time
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.
Inner North London
Concerns raised1
Failure to explain the need for sequential administration of two adrenaline auto injectors in acute anaphylaxis
This report raised 20 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.12
Action
Amend and release the Distance Learning Pack with stronger anaphylaxis guidance, second-dose adrenaline advice and accurate images of adrenaline autoinjectors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Amend NHS Pathways guidance so a second adrenaline autoinjector is advised after five minutes without improvement, through Release 20.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Disseminate prescribing, dosing, device-change and training guidance for adrenaline auto-injectors through safety bulletins, newsletters, intranet updates, scriptswitch messages and practice events.
Stated by NHS Enfield Clinical Commissioning GroupStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Follow up practices through meetings and training, and collate records confirming patient device training and dosage reviews.
Stated by NHS Enfield Clinical Commissioning GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Process AAI prescriptions as acute prescriptions and provide device-specific safety instructions covering appropriate dosing, carrying two pens and emergency action.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Train clinical staff on the three common AAI devices and maintain sample pens for patient demonstrations and training.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Deliver enhanced anaphylaxis content within mandatory basic life-support training, including symptom recognition, carrying two pens and device-specific administration.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Recruit an in-house pharmacist to provide current AAI guidance and patient training during prescribing and dispensing.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Appoint a Practice Anaphylaxis Champion to oversee staff awareness, training, prescribing surveillance, protocol adherence and patient reviews.
Stated by the three G.Ps that were interested persons in the above matterStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
Action
Amend the ScriptSwitch message with AAI availability, prescribing, dose-checking, counselling, training and allergy-action-plan requirements.
Stated by the three G.Ps that were interested persons in the above matterStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
Action
Have commissioning teams liaise with relevant organisations to facilitate uptake of new guidance and resources supporting management of severe allergies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Action
Consider whether communication routes or commissioning levers can support uptake and embedding of new allergy guidance and resources.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 August 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Matters of concern 1–14 and 20 do not concern NHS Pathways and fall outside its remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Manchester West
Concerns raised1
Failure to recognise when patient confidentiality should be breached to notify family or friends about patient safety or welfare concerns
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to provide families with the IDDSI definition of ‘bite sized’
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.3
Action
Review and update the dysphagia policy to incorporate current IDDSI standards.
Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Replace internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.
Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Action
Implement a staff checklist in patient records prompting and evidencing distribution of supportive and advisory documents.
Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
Staffordshire South
Concerns raised1
Failure to inform family members promptly about a fall
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.
Birmingham and Solihull
Concerns raised1
Failure to clearly communicate that non-conveyance constitutes rejection of medical advice to distressed patients or their families
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
Update the electronic patient report software to display a clear refusal-of-treatment, transport or referral statement before signing.
Stated by WMASStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2019.
Action
Revise the refusal-of-care policy to clarify clinician expectations when patients decline treatment.
Stated by WMASStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
Action
Amend the patient discharge advice leaflet to provide clearer guidance for patients left at the scene after ambulance attendance.
Stated by WMASStated completedThe respondent said that this action was complete when they made their response on 27 December 2019.
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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.
