First reported 13 Jan 2014•Latest report 24 Oct 2025
Definition
What this concern includes
Includes failures of the end-to-end coordination of patient care between hospitals, including engagement, transfer, treatment progression and ownership across specialist and non-specialist services.
Not included
Excludes coordination failures between organisations that are not hospitals or are unrelated to hospital-based patient care.
Excludes isolated communication, documentation or handover failures unless they demonstrate a broader failure of hospital-to-hospital care coordination.
Excludes generic staffing, resource or policy deficiencies that are not explicitly tied to coordination between hospitals.
Reports
25
Distinct published reports
Individual concerns
28
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
51
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.
NHS England7
Department of Health and Social Care5
Greater Manchester Health and Social Care Partnership2
Greater Manchester Mental Health NHS Foundation Trust2
Manchester University NHS Foundation Trust2
NHS Greater Manchester Integrated Care Board2
University Hospitals Sussex NHS Foundation Trust2
Blackpool Teaching Hospitals NHS Foundation Trust1
Bourne Leisure Limited1
Bristol NHS Foundation Trust1
Buckinghamshire Healthcare NHS Trust1
Central and North West London NHS Foundation Trust1
Derbyshire Community Health Services NHS Foundation Trust1
East Midlands Ambulance Service NHS Trust1
East of England Ambulance Service NHS Trust1
NHS trust21
Executive non-departmental public body8
Ministerial department5
Integrated care board3
Healthcare site2
Health-system partnership2
Private limited company2
Executive agency1
Non-ministerial department1
Registered charity1
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.
Nottinghamshire
Concerns raised1
Lack of policy prompts for cross-sector consultation in foreign-body cases
This report raised 11 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
Trial a joint physical and mental health policy for managing patients who insert foreign bodies, including joint meetings and impact review.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 October 2025.
Action
Implement and approve a new guideline for managing deliberately inserted foreign bodies, including clear MDT and mental-health consultation requirements.
Stated by Sherwood Forest Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2025.
Manchester South
Concerns raised1
Failure of coordinated discharge planning and joint working between trusts
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.9
Action
Establish an escalation pathway beyond the PTL meeting for delayed Mental Health Services discharges, bringing cases to GMMH senior leadership to support confirmation of hospital discharge dates.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025.
Action
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Operate a senior system Multi Agency Discharge Event forum to improve clinically ready-for-discharge escalation.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Develop a consistent end-to-end brokerage and funding pathway with responsibilities, stage time standards and a protocol for external-provider delays.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Provide additional voluntary, community and social-enterprise capacity in Manchester to prevent avoidable admissions and support timely discharge.
Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 20 May 2025.
Action
Roll out system-wide a four-level escalation policy for clinically ready-for-discharge mental-health patients by quarter three.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025.
Action
Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 May 2025.
Action
Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concern about lack of joint working is disputed because the case was repeatedly discussed at daily meetings involving the relevant organisations.
Stated by Manchester University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Failures to organise and coordinate inter-hospital transport
Ineffective interaction between people and systems across Southend and Basildon Hospitals
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.
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
Operate a focused weekly kidney and upper-tract urological cancer MDT reviewing relevant recent scans with specialist multidisciplinary participation across hospital sites.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2025.
Action
Use one comprehensive patient-tracking system across hospital sites to monitor cancer pathways, diagnostic reporting, timescales and required escalations.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Specialist renal consultant participation and cross-site hybrid MDT working are considered to have addressed concerns about decision-making and hospital interaction.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The transfer delay did not affect the clinical outcome because appropriate care was provided at Basildon Hospital.
Stated by Mid and South Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Urgent transfers are prioritised by the Trust and East of England ambulance service.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Coventry and Warwickshire
Concerns raised1
Inconsistent coordination between specialist and non-specialist hospitals
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 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.12
Action
Collaborate to produce recommendations addressing specialist contact, information sharing, renal care access, responsibility and care-location concerns.
Stated by The British Transplantation Society and UK Kidney Association (UKKA; formerly the Renal AssociationStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Maintain a master copy of local specialist centre contact details for switchboard.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Finalise, agree, and cascade shared guidelines for managing acutely unwell kidney-transplant inpatients.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Provide UHCW renal-team attendance at GEH to review renal inpatients on request, up to twice weekly, under the agreed SLA.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Consider using referapatient.org to document communication between renal departments and other hospitals.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2024.
Action
Agree referral indications and referral routes with George Eliot Hospital for specialist renal input.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Provide onsite renal consultant inpatient review at George Eliot Hospital and South Warwickshire Foundation Trust under service-level agreements.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Act as the primary specialist transfer centre for renal patients admitted to peripheral hospitals, regardless of their parent specialist unit.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Develop and share guidance with George Eliot Hospital on CMV sample tubes, urgent turnaround, contacts and escalation.
Stated by University Hospitals Coventry and Warwickshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Continue liaison with UHCW renal specialists to develop robust joint clinical guidelines.
Stated by George Eliot Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 November 2024.
Action
Maintain the consultant-to-consultant referral process for renal specialist advice and patient transfers.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Action
Provide twice-weekly UHCW renal specialist visits for renal patients at GEH under the existing service-level agreement.
Stated by George Eliot Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Oversight of delegated renal medicine services rests with individual Integrated Care Boards, including Coventry and Warwickshire ICB.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providers involved in the care should respond to concerns about local arrangements and processes, rather than NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The agreed guidelines, service-level agreement and related processes are considered sufficient to address the six concerns.
Stated by University Hospitals Coventry and Warwickshire NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Lack of a mechanism for multidisciplinary medical coordination under a single practitioner
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
Continue progressing the appointment of care coordinators for patients with complex medical needs.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Processes for managing complex patients across Greater Manchester specialties are better addressed by the Greater Manchester Integrated Care Board.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Delays and confusion in inter-hospital transfer coordination
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.1
Action
Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
Stated by University College London Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The transfer delay reflected unavailable UCLH beds and an unconfirmed referral by PRUH, although UCLH acknowledges confusion about the transfer arrangements.
Stated by University College London Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Failure of inter-hospital transfer arrangements to ensure timely transport of patients requiring specialist treatment
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.8
Action
Maintain additional ambulance capacity funded to expand capacity and improve response times.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Deliver new ambulances and specialist mental health vehicles.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Review all transfers of care from Spire Norwich Hospital to Norfolk and Norwich University Hospital during October 2021–October 2023.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Complete and register a hospital-level risk assessment addressing ambulance transfer delays.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Complete and register a group-wide risk assessment addressing ambulance transfer delays.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Actively explore alternative private ambulance providers for interfacility transfers, assessing their compatibility with emergency response and destination-facility systems.
Stated by Spire Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Join the local Inter Facility Transfer Group to support coordination of unplanned emergency patient transfers.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Continue working with Inter Facility Transfer Group members, including Norfolk and Norwich University Hospital, to mitigate interfacility transfer risks.
Stated by Spire Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Two local private ambulance providers could not contract for transfers because they were subcontracted to EEAST and lacked capacity.
Stated by Spire Healthcare LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Yorkshire and York
Concerns raised1
Failure to seek specialist input from the Leeds treating team
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.2
Action
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Contact York surgical colleagues to explain communication arrangements and discuss measures to prevent similar coordination failures.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Derby and Derbyshire
Concerns raised1
Lack of protocols ensuring safe and appropriate multi-party discharge arrangements
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 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.
Cornwall and Isles of Scilly
Concerns raised1
Lack of a service level agreement for treatment of patients from Cornwall when the UHP service is unavailable
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
Explore with University Hospitals Plymouth and Royal Cornwall Hospital what interim out-of-region thrombectomy referral support North Bristol can offer.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 November 2022.
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Includes failures of the end-to-end coordination of patient care between hospitals, including engagement, transfer, treatment progression and ownership across specialist and non-specialist services.
