First reported 21 Aug 2014•Latest report 21 Apr 2026
Definition
What this concern includes
Includes failures in the dedicated process for documenting, communicating, confirming or making available specialist clinical advice or treatment instructions to the clinicians or staff responsible for care.
Not included
Excludes generic clinical documentation or communication failures where specialist advice or instructions are not the material concern.
Excludes failures to seek or obtain specialist advice when the advice-recording, communication or confirmation process is not deficient.
Excludes failures involving patient-facing advice, routine handover or non-specialist instructions unless they are explicitly part of communicating or confirming specialist clinical advice.
Excludes failures to follow specialist advice after it was reliably recorded and communicated, where the advice-transfer process itself was not unsafe.
Reports
11
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
19
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.
Care Quality Commission2
Department of Health and Social Care2
East Kent Hospitals University NHS Foundation Trust2
General Medical Council2
NHS England2
Dartford and Gravesham NHS Trust1
Kent and Medway Mental Health NHS Trust1
Leeds Teaching Hospitals NHS Trust1
NHS Greater Manchester Integrated Care Board1
Parents of Kinga Cieciorska1
Recipient name withheld1
Royal College of Obstetricians and Gynaecologists1
Royal College of Physicians1
Royal College of Surgeons of England1
Springfield Home Care Services Limited1
NHS trust7
Executive non-departmental public body2
Health and care professional regulator2
Health and social care service regulator2
Health professional body2
Ministerial department2
Type not available2
Domiciliary care provider1
Healthcare site1
Integrated care board1
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.
Gateshead and South Tyneside
Concerns raised1
Failure to clearly communicate treatment plans and required actions in consultant correspondence
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
Produce national guidance on clear, concise, structured outpatient clinic letters and required primary-care actions.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Develop the Red Tape Challenge to improve primary-secondary care communication, interface working, prescribing, records access, interoperability, and process standardisation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implementation of measures improving primary-secondary care communication and prescribing is driven by integrated care boards, with national oversight.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Insufficient detail in neurology notes to communicate advice and clinical contact
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.
Mid Kent and Medway
Concerns raised1
Failure to document and communicate discharge medication recommendations
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
Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 14 March 2024.
Action
State in discharge notifications when medication has been reduced and record the reason.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 14 March 2024.
Newcastle upon Tyne and North Tyneside
Concerns raised1
Failure to communicate specialist wheelchair assessment and advice to care staff
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised2
Failure to document received specialist advice and confirm understanding
Failure to confirm and record specialist advice
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.9
Action
Maintain guidance requiring accurate records, detailed follow-up notes, discharge summaries, and prompt sharing of relevant postoperative information.
Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Endorse and support the Professional Record Standards Body’s standards for the structure and content of health and care records.
Stated by Royal College of Surgeons of EnglandStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Highlight the absence of standards verifying verbally provided clinical advice accuracy to the Professional Record Standards Board.
Stated by Royal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Propose developing standards specifying which elements of remote clinical advice should be documented to ensure effectiveness and prevent harm.
Stated by Royal College of PhysiciansStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Continue advocating for integrated electronic record systems within the NHS to support safer recording and verification of clinical advice.
Stated by Royal College of PhysiciansStated in progressThe respondent said that this action was in progress when they made their response on 4 January 2021.
Action
Embed documentation of specialist advice in the Junior Doctors’ curriculum.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Introduce Electronic Patient Records to strengthen real-time documentation of specialist advice.
Stated by Ashford and St Peter'S Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 January 2021.
Action
Reinforce contemporaneous documentation of verbal clinical advice in patient records.
Stated by NHS England and ImprovementStated completedThe respondent said that this action was complete when they made their response on 4 January 2021.
Action
Introduce electronic patient records to enable real-time documentation of specialist advice.
Stated by NHS England and ImprovementStated plannedThe respondent said that this action was planned when they made their response on 4 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Specific advice to physicians on recording and verifying clinical advice falls outside the organisation’s role and is covered by GMC guidance.
Stated by Royal College of PhysiciansOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for recording telephone advice was considered to rest with the recipient, not the doctor providing the advice.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The completed hospital Significant Incident investigation was considered to have addressed the issues, so no further regulatory action was required.
Stated by General Medical CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North East Kent
Concerns raised1
Failure to record consultant telephone advice
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire Eastern
Concerns raised1
Failure to record senior clinician advice in electronic notes
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
Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Action
Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
Stated by Leeds Teaching Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Brighton and Hove
Concerns raised1
Failure to communicate and document specialist treatment instructions
This report raised 17 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 record the identity of the specialist clinician giving advice
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.
North and West Cumbria
Concerns raised1
Lack of formal recording of sudden clinical interactions
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
Implement an electronic system to record details of advice provided to healthcare professionals at other hospitals.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Ensure the Cardiothoracic Surgical Team consistently uses the electronic system for external requests for medical opinions.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Include electronic-system recording requirements in the induction programme for newly recruited and rotating staff.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 November 2014.
Action
Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 November 2014.
Pin
Get email alerts
Request correction
Includes failures in the dedicated process for documenting, communicating, confirming or making available specialist clinical advice or treatment instructions to the clinicians or staff responsible for care.
