Recurring concern
Unreliable documentation and communication of shared clinical decisions
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Request correctionFirst reported 5 Dec 2014•Latest report 5 Feb 2026
What this concern includes
Includes failures to establish, document, communicate or preserve shared clinical decisions, assessment outcomes, specialist advice and resulting actions between professionals involved in patient care, where the deficiency can cause confusion, duplicated or omitted action, or unsafe follow-up.
Not included
- Excludes generic communication failures between professionals where no shared clinical decision, assessment outcome, clinical advice or resulting action is the deficient object.
- Excludes deficiencies in the substantive clinical decision or advice when it was clearly documented and communicated but clinically inappropriate.
- Excludes general clinical record-keeping failures unrelated to documenting and communicating shared professional decisions.
- Excludes patient- or family-facing communication failures unless they are part of communicating the shared clinical decision between the responsible professionals.
- Reports
- 9
- Individual concerns
- 9
- Date range
- 2014–2026
- Stated actions
- 10
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to ensure communication of agreed sitting-out recommendations between physiotherapy and nursing professionals across the Trust
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 concernsEach 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
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Action
Maintain consistent Trust-wide use of seating charts and documentation of allied health professional recommendations in HIVE for communication and care planning.
Stated by Manchester University NHS Foundation Trust -
Action
Extend the Wythenshawe audit of physiotherapy assessments and nursing review processes across the Trust and report findings through hospital quality and safety groups.
Stated by Manchester University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust disputes that communication and documentation measures for sitting-out recommendations were isolated to Doyle Ward, stating they apply consistently across all inpatient areas.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Lack of a formal documented process for referrals and subsequent advice
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to document consultant clinical discussions
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 concernsEach 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
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Action
Use an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Stated by Department of Health and Social Care
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Position
Existing consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Lack of documented agreement on assessment outcomes between professionals
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 concernsEach 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.2
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Position
The Mental Health Act assessment system is designed to produce clear outcomes, with disagreement between assessors serving as an intended safeguard.
Stated by Royal College of Psychiatrists
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Position
AMHPs are responsible for recording assessment outcomes and communicating decisions and reasons to relevant professionals.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to consistently document the content and timing of inter-hospital clinical conversations
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 concernsEach 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
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Action
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Scope improvements to recording patient information for patients needing specialist advice while off site.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Work with the Norse supplier to transition to the system’s latest version and additional features.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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Action
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Remind clinicians to keep contemporaneous notes of advice given to district general hospitals by placing a note in patients’ records.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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Concerns raised1
Failure to record pharmacist-clinician discussions and advice
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to involve and record discussions with the primary surgeon before remounting the valve
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in sending assessment circumstances and outcomes to GPs
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 concernsEach 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
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Action
Implement an MHLS standard requiring assessment letters to be drafted within the same or following shift and dispatched within three working days.
Stated by Black Country Healthcare NHS Foundation Trust
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Concerns raised1
Poor documentation of referral-management decisions
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 concernsEach 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
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Action
Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
Stated by Sussex Partnership NHS Foundation Trust
Data last updated 7 September 2026