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.
Staffordshire and Stoke-on-Trent
Concerns raised2
Lack of shared accessible medical notes across hospital teams
Reliance on manual transcription of treatment decisions between medical 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
Develop a digital vision and strategy including a goal for a new electronic patient record across the Integrated Care System.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Action
Draft a business case with the Integrated Care System to apply for NHS funding for an interoperable electronic patient record.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A single Trust-wide EPR cannot currently be implemented because it requires substantial investment, development and deployment time, and existing infrastructure is limited.
Stated by University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Worcestershire
Concerns raised1
Failure to ensure overall consultant responsibility for patients receiving care from multiple teams
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
Share, approve and implement the agreed policy for managing medical outliers and assigning overall responsibility for their care.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2024.
Inner North London
Concerns raised1
Failure to establish daily skin-integrity monitoring responsibility
This report raised 8 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.14
Action
Establish a dedicated telephone number and contact time for discussing hospital discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Invite District Nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Set up a dedicated telephone line and contact time for nurses to discuss hospital discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Invite district nurses to University College Hospital NHS Trust meetings for complex discharges.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Share discharge communications and care plans with all providers involved in patients’ care.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review and improve information shared with carers before vulnerable adults are discharged, including holistic-care instructions and pressure-damage prevention equipment.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Provide the UCLH discharge team with district-nursing contact details and weekday availability for discussing discharges.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care to incorporate pressure-ulcer and other relevant needs into care plans.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Ensure robust and timely communication with all agencies involved in care arrangements.
Stated by Kapital Care (UK) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Establish direct communication links between the hospital discharge team and district nurses for discharge discussions.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Hold monthly partnership meetings with community health services to develop joint working and improve understanding of district-nurse roles.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Provide joint education and training with community health services to clarify roles and responsibilities and reduce care gaps.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Contact district nurses whenever they are involved in an adult’s care arrangements.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North Yorkshire and York including North Yorkshire Western District
Concerns raised1
Failure of communication and shared information across autism and mental health teams
This report raised 9 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
Work with TEWV to resolve internal and external communication issues affecting patient care.
Stated by NHS Humber and North Yorkshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Examine patients with autism and EUPD/BPD diagnoses to assess diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Examine records for diagnostic validity, communication, withdrawal, reasonable adjustments and tailored therapeutic options for patients with autism and EUPD diagnoses.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Introduce the CITO recording system across all services to clarify diagnoses and support patient record access.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Share learning with clinical teams and work with external partners to improve timely, constructive communication and cohesive patient care.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
TEWV is responsible for delivering core mental health care and making reasonable adjustments for patients with autism.
Stated by NHS Humber and North Yorkshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Lack of clarity about relative responsibility for patients’ overall medical management between Mayday Assistance Limited and air ambulance providers
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
Establish Air Ambulance Support Agreements with providers to clarify responsibilities and promote close working relationships on all cases.
Stated by Mayday Group LtdStated completedThe respondent said that this action was complete when they made their response on 26 August 2021.
Manchester South
Concerns raised1
Failure to provide detailed and documented shared risk assessments and care plans in acute settings
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.3
Action
Design and implement integrated care pathways linking liaison psychiatry teams with community mental-health services, including timely information sharing.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Use joint assessment, handover and working-plan documentation to record risk, observation levels, clinical plans and handovers between liaison and emergency-department teams.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Action
Embed a standard operating procedure across both organisations reflecting shared-care principles.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local clinicians and operational managers are responsible for the safety of handover and patient management between acute and mental health services.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Brighton and Hove
Concerns raised2
Lack of clear allocation of overall responsibility for care
Lack of a clear inter-organisational working policy
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.3
Action
Finalise the Trust-wide CRHT operational policy, including referral pathways and defined responsibilities for services supporting patients awaiting admission.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2020.
Action
Run a daily Urgent Demand Oversight meeting to review admission demand, available resources and support packages for patients awaiting hospital care.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 December 2020.
Action
Finalise a Brighton and Hove flowchart and local protocol clarifying how AMHPs secure care or treatment while patients await admission.
Stated by Brighton and Hove City CouncilStated plannedThe respondent said that this action was planned when they made their response on 29 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing urgent demand meetings, Haven availability and agreed AMHP operational arrangements are considered sufficient to prevent the identified confusion recurring meanwhile.
Stated by Brighton and Hove City CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of care coordinators to lead support and best-interests processes in acute settings
This report raised 9 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.8
Action
Provide assessment wards and the Emergency Department with a full Integrated Discharge Team service and assign a lead care coordinator for each patient's discharge planning.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide a single hospital-based care coordinator for each patient and record coordination input in electronic and social services records.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 June 2020.
Action
Establish a single care-coordinator point of contact, with care coordinators providing hospital in-reach for involved service users.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Action
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 June 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Bolton Council and GMMHFT will provide the full response to concerns about community care coordination and agency roles.
Stated by Bolton NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Greater Manchester Mental Health Foundation Trust addresses care coordinator responsibilities.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Bolton NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust and Bolton Council are responsible for responding to the report’s specific concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
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
Lack of a formalised joint process for reviewing treatment plans and determining optimum medical and psychiatric care
Lack of effective coordination of shared psychiatric and acute medical care
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.9
Action
Operate joint mental health inpatient transfer and return-transfer pathways covering physical deterioration, chronic conditions and required clinical information.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 May 2020.
Action
Develop and trial a joint standard operating procedure for older mental health inpatients requiring medical input.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 May 2020.
Action
Provide documented self-directed training on the approved joint standard operating procedure to all relevant staff.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 May 2020.
Action
Implement the joint Standard Operating Procedure for shared physical and mental healthcare of older inpatients requiring medical input.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 May 2020.
Action
Create and apply structured pathways for acute deterioration, chronic-condition advice, information gathering, and transfers of care.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 May 2020.
Action
Establish working parameters and pilot Digital Health Team support for physical health needs on Summers and Hague wards.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 May 2020.
Action
Establish working parameters for Digital Health Team support to older mental health inpatients on Summers and Hague wards.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 May 2020.
Action
Conduct an eight-week Digital Health services pilot and review it to determine a more formal service offer and outcomes.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 May 2020.
Action
Deliver and document self-directed training for staff covered by the approved joint SOP.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 May 2020.
Manchester South
Concerns raised1
Lack of communication between midwifery and social work teams
This report raised 8 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.
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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.
