First reported 27 Sep 2013•Latest report 22 Dec 2025
Definition
What this concern includes
Includes failures of dedicated communication arrangements between clinical specialties involved in the same patient's care, including absent or ineffective formal frameworks, unclear communication routes, poor exchange of plans and actions, and unreliable communication in complex or dynamically changing cases, including across NHS Trusts.
Not included
Excludes generic communication or information-sharing failures where no inter-specialty clinical-care context is identified.
Excludes failures confined to a single specialty's internal communication, documentation or clinical decision-making.
Excludes inter-agency coordination concerns involving non-clinical agencies or services unless the assertion specifically concerns communication between clinical specialties.
Excludes failures in a separately named pathway, such as radiology coordination, clinical handover or a condition-specific referral system, where that named process provides the more specific supported boundary.
Reports
17
Distinct published reports
Individual concerns
18
A report can raise multiple concerns
Date range
2013–2025
First to latest report issue date
Stated actions
34
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 Care3
Manchester University NHS Foundation Trust3
Barts Health NHS Trust2
NHS England2
Aneurin Bevan University LHB1
Association Of British Neurologists1
Bournemouth, Christchurch and Poole Council1
Bristol NHS Foundation Trust1
Care Quality Commission1
College of Policing1
Dorset County Council1
Dorset Healthcare University NHS Foundation Trust1
Dorset Police1
King'S College Hospital NHS Foundation Trust1
Lincolnshire County Council1
NHS trust14
Integrated care board4
Executive non-departmental public body3
Ministerial department3
English county council2
Multi-service care provider2
Registered charity2
English unitary authority1
Health and social care service regulator1
Health professional body1
Local health board1
National policing body1
Police force1
Professional body1
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.
Northamptonshire
Concerns raised1
Failure to communicate medication changes between private and NHS psychiatric providers
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.
Manchester South
Concerns raised2
Lack of a formal framework for inter-specialty communication
Failure of specialties to communicate about patients’ plans and actions
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.
Inner West London
Concerns raised1
Failure of communication between clinical teams and within referrals
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 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
Reinforce thorough contemporaneous documentation and team communication through resident doctor induction and training.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Formalise written referrals to paediatric gastroenterology in the patient record.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Roll out written referrals with documented outcomes to all specialty consultation requests across the paediatric directorate.
Stated by St George'S University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 July 2025.
Action
Hold monthly Paediatric Gastroenterology Radiology meetings to discuss complex cases and record outcomes in the electronic patient record.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 July 2025.
Action
Update the national paediatric gastroenterology service specification to reference second-opinion guidance and strengthen multidisciplinary communication and discussion of unexpected investigation results.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local aspects of Samuel’s care fall outside the national policy and programmes addressed within NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust should respond to concerns about its local management of Samuel’s care and provide further information.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of clear guidance for communication of test results and patient presentation across specialisms and team roles
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.
Manchester South
Concerns raised1
Poor communication and fragmented input across trusts
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.3
Action
Update the GM Care Record webpage and relaunch the system to raise awareness of its information-sharing capabilities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Update GM Care Record eLearning to support access to and use of the system.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide additional training on how to access and use the GM Care Record.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Nottinghamshire
Concerns raised1
Lack of effective communication between Multi-Disciplinary Teams from different specialisms for patients on more than one treatment pathway
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.8
Action
Distribute a Trust-wide safety briefing on risks affecting patients on multiple specialty pathways.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
Action
Implement Careflow referral capability for all Cancer MDTs.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Implement direct Pathology Medway referrals for Cancer MDTs.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Agree and pilot a standardised cross-Trust MDT referral process.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Write overarching and individual MDT standard operating procedures to standardise MDT processes.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Streamline internal and external MDT outcome distribution, including development of web-based Infoflex recording and verification.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Develop and deliver standardised induction and refresher training for MDT coordinators.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 November 2023.
Action
Operate a monthly MDT Excellence meeting with representation from each clinical division.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 November 2023.
Gwent
Concerns raised1
Failure of direct communication between mental health and ENT teams
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.1
Action
Expand Adferiad through recurrent funding, broader eligibility and a multidisciplinary team providing assessment, care planning and rehabilitation expertise.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 4 October 2022.
Dorset
Concerns raised1
Lack of communication between neurology and psychiatric teams
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.3
Action
Support solutions to poor integration and communication between neurological and mental health services.
Stated by Royal College of PsychiatristsStated in progressThe respondent said that this action was in progress when they made their response on 28 September 2022.
Action
Discuss with the Royal College of Psychiatrists’ President how to improve communication between psychiatric and neurology teams.
Stated by Association Of British NeurologistsStated plannedThe respondent said that this action was planned when they made their response on 28 September 2022.
Action
Undertake an eight-week review of Dorset epilepsy nursing resources, provision across care settings, relevant specialty interactions, and neurology–psychiatry communication processes.
Stated by NHS Dorset Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 28 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Communication between neurology and psychiatric teams concerns national bodies rather than the Trust, so the Trust will not comment further.
Stated by Dorset Healthcare University NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for improving communication between neurology and psychiatric teams lies nationally, not with the local Trust.
Stated by University Hospitals Dorset NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cheshire
Concerns raised1
Failure to colocate the resuscitation area with the operating theatre for effective obstetric-neonatal communications
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.
Inner North London
Concerns raised1
Failure to maintain an effective formal relationship between paediatric hepatology and paediatric intensive care
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.1
Action
Develop a bespoke organisational-development package to improve collaboration, communication and conflict management between hepatology and paediatric intensive care.
Stated by King'S College Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 March 2022.
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Includes failures of dedicated communication arrangements between clinical specialties involved in the same patient's care, including absent or ineffective formal frameworks, unclear communication routes, poor exchange of plans and actions, and unreliable communication in complex or dynamically changing cases, including across NHS Trusts.
