First reported 1 May 2015•Latest report 15 Jun 2026
Definition
What this concern includes
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.
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.
Reports
29
Distinct published reports
Individual concerns
33
A report can raise multiple concerns
Date range
2015–2026
First to latest report issue date
Stated actions
106
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 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
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.
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.
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
Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Revise the prison healthcare partnership agreement to add Department of Health and Social Care and Ministry of Justice oversight and accountability.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 16 August 2019.
Action
Review and improve commissioning and links across health, justice, local authority, probation and community services to align provision before, during and after custody.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 16 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
NHSE/I is responsible for commissioning healthcare in English prisons, not HMPPS.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England is responsible for commissioning healthcare services for prisoners.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The National Prison Healthcare Board is responsible for overseeing and managing the partnership agreement and delivering its shared objectives.
Stated by Department of Health and Social CareRedirects 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.
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
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.
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
Implement a staff protocol for coordinating NHS care with private psychiatric treatment and explaining the process to patients.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A standard MOU with all private psychiatrists cannot be agreed because the Trust may work with numerous providers across its geography.
Stated by Central and North West London NHS Foundation TrustUnable 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.
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.10
Action
Modify patient letters to explain blood-test arrangements clearly and provide an SRFT contact for monitoring difficulties.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Ask GPs before ESA treatment whether they can monitor bloods, record responses electronically, agree monitoring plans, and follow up non-responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Assume responsibility for taking bloods until the GP responds, ensuring clinically necessary ESA treatment can begin.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Develop and implement a standard operating policy covering ESA blood-monitoring arrangements, outstanding responses, and negative responses.
Stated by Northern Care Alliance NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Write to existing ESA patients to identify difficulties accessing monitoring and manage identified difficulties under the agreed policy.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Explore a Greater Manchester commissioned shared-care protocol for ESA monitoring through CCGs and the Medicines Management Group.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2019.
Action
Establish an operating procedure requiring direct GP communication and a provider response before confirming monitoring-dependent treatment plans.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Describe the shared-care model in a business case for consideration by the Greater Manchester Medicines Management Group and local commissioners.
Stated by NHS Oldham CCGStated plannedThe respondent said that this action was planned when they made their response on 2 June 2019.
Action
Identify patients receiving or potentially requiring shared-care ESA pathways and write to GP practices to promote robust monitoring.
Stated by NHS Oldham CCGStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Action
Notify the CCG that the Practice was asked to monitor a red-status medication and report the associated significant event.
Stated by St Chads Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 2 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The community nursing service was commissioned to provide phlebotomy only for housebound patients, and this patient was not housebound.
Stated by Pennine Care NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Practice should not accept responsibility for monitoring EPO; the CCG will liaise directly with the Trust and medicines management.
Stated by St Chads Medical PracticeRedirects 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.
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
Complete an inspection addressing the reported concerns, including end-of-life care and Mental Capacity Act arrangements.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
CQC does not prescribe how providers should improve; the provider or registered manager decides the appropriate actions.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
CQC does not publish detailed standards for specific conditions because this would duplicate expert sources and be impractical to keep updated.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Care Quality Commission, as regulator, is expected to consider and respond to concerns about the services provided in this case.
Stated by Department of Health and Social CareRedirects 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.
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
Retrain all shared-care staff on the standard operating protocol, escalation procedures, and multidisciplinary shared-care discussions.
Stated by Addiction Dependency SolutionsStated plannedThe respondent said that this action was planned when they made their response on 15 February 2018.
Manchester West
Concerns raised1
Failure of communication between specialist teams caring for patients under shared care
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
Discuss shared-care communication concerns at the Trust’s Clinical Advisory Board.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Develop a shared-care guidance note reminding clinical staff of their communication responsibilities.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Distribute the approved shared-care guidance to clinical staff and upload it to the Trust’s policy library.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Monitor the shared-care actions through the Quality and Safety Committee with updates every two months.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The absence of direct communication between surgical and cardiology teams did not contribute to the deceased’s death.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Daily reviews and documented management plans provided sufficient shared-care communication, so direct discussion was not indicated.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Much shared-care communication responsibility rests with clinicians’ obligations under the GMC’s Good Medical Practice guidance.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustRedirects 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.
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.
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.
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
Maintain a Service Level Agreement with the local GP practice for joint care.
Stated by Ashfield House Surgery and Partnerships in Care LimitedStated completedThe respondent said that this action was complete when they made their response on 1 May 2015.
Pin
Get email alerts
Request correction
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.
