Includes failures of the explicitly shared-care process, including unclear arrangements for documenting discussions, ineffective coordination between organisations or teams, and failures to communicate decisions or responsibilities across shared-care providers.
What is not included
Excludes generic record-keeping failures not tied to an explicitly shared-care arrangement.
Excludes generic communication or multidisciplinary-discussion failures where shared care is not the named process.
Excludes failures confined to a single provider's assessment, treatment, staffing or resources without a shared-care coordination link.
Trends
Reports over time
Reports mentioning this concern, 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 Care10
NHS England6
Greater Manchester Mental Health NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
NHS Northamptonshire Integrated Care Board2
Northamptonshire Healthcare NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
ADS (Addiction Dependency Solutions)1
Aneurin Bevan University LHB1
Ashfield House Surgery1
Bamford Grange Care Home1
Bolton Borough Council1
Brighton and Hove City Council1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
NHS trust18
Ministerial department10
Executive non-departmental public body7
Integrated care board5
Healthcare site3
Company1
Domiciliary care provider1
English metropolitan district council1
English unitary authority1
Executive agency1
Health and social care service regulator1
Health-system partnership1
Independent healthcare provider1
Local health board1
London borough council1
Reports and published responses 29 reports
See individual reports that have raised this concern, and the actions taken in response
East Sussex
Concerns raised1
Fragmentation of responsibility for prison healthcare across multiple organisations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
HM Prison and Probation Service
NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
NHS England
Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.
Department of Health and Social Care
Revise the prison healthcare partnership agreement to add Department of Health and Social Care and Ministry of Justice oversight and accountability.
Department of Health and Social Care
Review and improve commissioning and links across health, justice, local authority, probation and community services to align provision before, during and after custody.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
HM Prison and Probation Service
NHSE/I is responsible for commissioning healthcare in English prisons, not HMPPS.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
NHS England is responsible for commissioning healthcare services for prisoners.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
The National Prison Healthcare Board is responsible for overseeing and managing the partnership agreement and delivering its shared objectives.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to provide care coordination after placement with a private provider
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring 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
Lack of joint-working arrangements between the NHS and private psychiatric consultants
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Central and North West London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Central and North West London NHS Foundation Trust
Implement a staff protocol for coordinating NHS care with private psychiatric treatment and explaining the process to patients.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Central and North West London NHS Foundation Trust
A standard MOU with all private psychiatrists cannot be agreed because the Trust may work with numerous providers across its geography.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester North
Concerns raised1
Failure to establish shared care arrangements or identify an organisation for blood sampling for drug monitoring
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS Oldham CCG
Northern Care Alliance NHS Foundation Trust
Pennine Care NHS Foundation Trust
St Chads Medical Practice
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Northern Care Alliance NHS Foundation Trust
Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
Northern Care Alliance NHS Foundation Trust
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
Northern Care Alliance NHS Foundation Trust
Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
Northern Care Alliance NHS Foundation Trust
Develop and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
Northern Care Alliance NHS Foundation Trust
Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
Northern Care Alliance NHS Foundation Trust
Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
NHS Oldham CCG
Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
NHS Oldham CCG
Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
NHS Oldham CCG
Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
St Chads Medical Practice
Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Pennine Care NHS Foundation Trust
The community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
Outside remitThe respondent said that this matter was outside its role or authority.
St Chads Medical Practice
The Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to establish clear responsibility for PEG feeding assessment and key decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Care Quality Commission
Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Care Quality Commission
CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Department of Health and Social Care
The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Unclear documentation of shared care discussions
Unclear facilitation of shared care discussions
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Addiction Dependency Solutions
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Addiction Dependency Solutions
Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.
Manchester West
Concerns raised1
Failure of communication between specialist teams caring for patients under shared care
Linked response
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Discuss shared-care communication concerns at the Trust’s Clinical Advisory Board.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Develop a shared-care guidance note reminding clinical staff of their communication responsibilities.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Distribute the approved shared-care guidance to clinical staff and upload it to the Trust’s policy library.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Monitor the shared-care actions through the Quality and Safety Committee with updates every two months.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
The absence of direct communication between surgical and cardiology teams did not contribute to the deceased’s death.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Daily reviews and documented management plans provided sufficient shared-care communication, so direct discussion was not indicated.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust
Much shared-care communication responsibility rests with clinicians’ obligations under the GMC’s Good Medical Practice guidance.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gloucestershire
Concerns raised1
Lack of a process for sharing information and joining up care between community and obstetric providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Lack of a clear service level agreement for PIC and GP joint care
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Ashfield House Surgery
Partnerships in Care Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Ashfield House Surgery and Partnerships in Care Limited
Maintain a Service Level Agreement with the local GP practice for joint care.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.