Recurring concern

Unreliable inter-agency information sharing for coordinated care

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First reported 29 May 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the inter-agency care information-sharing system, including inadequate arrangements, communication channels, shared records or contact mechanisms when these prevent timely access to relevant care, needs or risk information between agencies.

Not included

Excludes information-sharing failures unrelated to coordination between agencies supporting a person.
Excludes failures confined to a single organisation's records, assessment, documentation or communication process unless the report directly links them to inter-agency information sharing.
Excludes generic staffing, confidentiality, policy or technology deficiencies that are not specifically tied to the unsafe inter-agency information-sharing condition.
Excludes hazards involving public access to harmful information or physical communication and rescue equipment.

Reports: 212
Individual concerns: 235
Date range: 2013–2026
Stated actions: 492

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care57

NHS England39

Ministry of Justice14

Home Office11

Greater Manchester Health and Social Care Partnership9

HM Prison and Probation Service8

NHS Greater Manchester Integrated Care Board8

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

Birmingham and Solihull Mental Health NHS Foundation Trust6

Metropolitan Police Service6

College of Policing5

Greater Manchester Police5

Midlands Partnership University NHS Foundation Trust5

Pennine Care NHS Foundation Trust5

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.

19 Apr2022
Surrey
Concerns raised1
1. Failure to share medical information with other agencies
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Volodymyr KOROL · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Volodymyr Korol died from a fatal ventricular arrhythmia in his bedroom at Shrewsbury Court Independent Hospital on 1 August 2020, following cardiac and other physical health conditions. The inquest identified concerns including failures to assess his capacity regarding weight management, investigate and manage cardiac and other physical health conditions, share medical information, and escalate abnormal vital signs. The Coroner was concerned that similar practices might be present at another site operated by Whitepost Healthcare Group.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share medical information with other agencies
Wider context from the report
“Following Mr Korol’s death Shrewsbury Court Independent Hospital did not declare a Serious Incident. As such, whilst there was a 72 hour serious incident review into the events of 31 July and 1 August 2020, there was no investigation into the wider circumstances leading up to his death. Accordingly, none of the matters which form part of the jury’s narrative conclusion were identified by Shrewsbury Court Independent Hospital either at the time as part of their own internal investigation or thereafter as part of their preparation for the inquest. The court heard evidence that Shrewsbury Court Independent Hospital has now closed down but that Whitepost Healthcare Group continues to operate one other site, namely Iden Manor Nursing Home in Kent. The jury found that there were a number of causative failures in relation to the carrying out of mental capacity assessments, the sharing of medical information with other agencies and the appropriate escalation of vital signs which fall outside of normal parameters. All of these issues are equally as important in nursing homes as they are in psychiatric hospitals. Given that these issues were not identified and acted upon by Whitepost Healthcare Group at any point prior to the inquest, the Coroner is concerned that similar practices may be present at Iden Manor Nursing Home in Kent, which would present a risk of future deaths. In the circumstances the Coroner considers that practices should be audited at Iden Manor Nursing Home to ensure that the deficient practices identified by the jury in relation to Mr Korol’s care at Shrewsbury Court Independent are not present at Iden Manor Nursing Home. ”
Source location
Volodymyr KOROL · Prevention of Future Deaths report
Page 7 · concerns
Open source report
28 Mar2022
North East Kent
Concerns raised1
1. Failure to share crucial clinical information between healthcare organisations
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Hayley Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Hayley Smith developed severe and enduring anorexia nervosa and died on 29 December 2019 after an out-of-hospital cardiac arrest caused by severe hypoglycaemia. The inquest identified inadequate communication and information-sharing between the organisations involved in her care, including failures to share information about her Community Treatment Order.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share crucial clinical information between healthcare organisations
Wider context from the report
“(1) Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes: I. South London and the Maudsley NHS Foundation Trust (SLAM) II. North East London NHS Foundation Trust (NELFT locally known as the Kent and Medway Eating Disorders Team) III. The White House IV. Kings College NHS Foundation Trust (Kings) V. General Practitioner (GP) VI. East Kent Hospitals NHS Trust (EKHT for Queen Elizabeth the Queen Mother) VII. South East Coast Ambulance Service (2) The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The White House were not sent copies of clinical correspondence and at the time did not have access to GP records although since Hayley’s death do now have access to GP records. The mental health team at NELFT were responsible for managing Hayley’s CTO despite the fact that she was placed out of their geographical area but were not aware she had been seen by either the ambulance service or by Queen Elizabeth the Queen Mother hospital. (3) The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. It is highly likely that the paramedic at South East Coast Ambulance Trust who attended Hayley on 23rd December or the emergency department nurse who saw her at Queen Elizabeth the Queen Mother hospital on 24th December 2019 been aware that Hayley was on a CTO they or her treating mental health team would have been able to take steps which would have saved her life. (4) Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding. (5) Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today. ”
Source location
Hayley Smith · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Mar2022
North East Kent
Concerns raised1
1. Inadequate timely communication and follow-up action between agencies
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 4
1. Action
  Work with the Children’s Commissioner’s Office and Information Commissioner’s Office to identify ways to improve data sharing in child safeguarding cases.
  Stated by Department for EducationStated in progress
2. Action
  Invest in new strategic leadership posts to improve inter-agency dialogue and provide rapid escalation and resolution.
  Stated by Kent and Medway Clinical Commissioning GroupStated completed
3. Action
  Develop and implement shared Kent and Medway escalation policies and protocols for complex, high-risk children and young people.
  Stated by Kent and Medway Clinical Commissioning GroupStated completed
1. Action
  Create joint posts across local authority and primary care to identify children with additional needs early and coordinate care rapidly.
  Stated by Kent and Medway Clinical Commissioning GroupStated completed
Respondent positions 1
1. Position
  Kent local authority is responsible for undertaking assessments and providing services for children in need, including disabled children.
  Stated by Department for EducationRedirects responsibility
AI-generated summary

Samuel Alban Stanley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Samuel Alban Stanley died in hospital on 26 April 2020 from injuries sustained during an episode of high-risk behaviour related to his Prader-Willi syndrome. The report raised concerns about inadequate support for him and his family, limited access to appropriate services, and poor communication between agencies.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate timely communication and follow-up action between agencies
Wider context from the report
“(4) The evidence at the inquest also revealed that communication between agencies involved in his short life was inadequate. It is possible that had information been shared in a timely manner and actions taken as a result then more support could have been provided to Sammy and his family. Had he, and his family, had more practical help and support this may have made a difference to his high-risk behaviour and ultimately his death. ”
Source location
Samuel Alban Stanley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the Children’s Commissioner’s Office and Information Commissioner’s Office to identify ways to improve data sharing in child safeguarding cases.

Verbatim wording from the response
“Working together to safeguard children (2018), is clear that local areas should have a comprehensive range of effective, evidence-based services in place to address needs, and that effective sharing of information between practitioners and local organisations and agencies is key. We agree that missed opportunities to share information in a timely manner can have severe consequences for the safety and welfare of children and young people. On the 23rd May 2022, the Department for Education made a statement in Parliament about the final report arising from the review of Children's Social Care. To support delivery of recommended changes, the department are already working with the Children’s Commissioner’s Office and the Information Commissioner's office (ICO) to identify ways to better improve data sharing in child safeguarding cases.”

Source location
Response from Department for Education
Page 2 · response
Published 17 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Invest in new strategic leadership posts to improve inter-agency dialogue and provide rapid escalation and resolution.

Verbatim wording from the response
“KMCCG have worked with NELFT, acute and community trusts, KCC, NHS England and wider partners to improve communications regarding children and young people who have the most complex presentations and are considered at risk. KMCCG has invested in new strategic leadership posts whose role is to drive improved dialogue across agencies and to provide a route for rapid escalation and resolution. Since Sammy’s death, KMCCG have worked in collaboration with system partners to develop and implement shared Kent and Medway escalation policy and protocols. This enables rapid identification of children and young people who need senior leader oversight to ensure appropriate care.”

Source location
Response from Kent and Medway Clinical Commissioning Group
Page 4 · response
Published 17 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and implement shared Kent and Medway escalation policies and protocols for complex, high-risk children and young people.

Verbatim wording from the response
“KMCCG have worked with NELFT, acute and community trusts, KCC, NHS England and wider partners to improve communications regarding children and young people who have the most complex presentations and are considered at risk. KMCCG has invested in new strategic leadership posts whose role is to drive improved dialogue across agencies and to provide a route for rapid escalation and resolution. Since Sammy’s death, KMCCG have worked in collaboration with system partners to develop and implement shared Kent and Medway escalation policy and protocols. This enables rapid identification of children and young people who need senior leader oversight to ensure appropriate care.”

Source location
Response from Kent and Medway Clinical Commissioning Group
Page 4 · response
Published 17 March 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create joint posts across local authority and primary care to identify children with additional needs early and coordinate care rapidly.

Verbatim wording from the response
“Since Sammy’s death, KMCCG has made investments in posts and mechanisms to improve the offer for children and young people with neurodevelopmental presentation. A number of joint posts have been created across the Local Authority and Primary Care so that children and young people with additional needs are identified early and care is coordinated rapidly around the child and family.”

Source location
Response from Kent and Medway Clinical Commissioning Group
Page 5 · response
Published 17 March 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Kent local authority is responsible for undertaking assessments and providing services for children in need, including disabled children.

Verbatim wording from the response
“I am sorry to hear that Samuel was not offered the care and treatment that he needed to keep him safe, and for the poor communication between the agencies that were supposed to provide this care. Local authorities have a duty under s17 of the Children Act 1989 to carry out an assessment of children in need and to provide services to them for the purpose of safeguarding and promoting their welfare. Working together to safeguard children (2018), sets out that safeguarding partners should agree with their relevant agencies the levels for the different types of assessment and services to be delivered, including services for disabled children. Safeguarding partners should then publish a threshold document setting out local criteria for action, including procedures and processes for cases relating to disabled children. It would therefore be for Kent local authority to undertake this.”

Source location
Response from Department for Education
Page 2 · response
Published 17 March 2022
Open published response
11 Feb2022
Manchester South
Concerns raised1
1. Failure of agencies to share information and undertake joint assessment and planning
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 3
1. Action
  Implement the Community Mental Health Framework with named keyworkers, multidisciplinary teams and joined-up personalised care planning.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Operate the GM Care Record across Greater Manchester health and mental health providers, GPs and hospitals to share information for care coordination.
  Stated by NHS Greater Manchester Integrated Care BoardStated completed
3. Action
  Add social care data feeds to the GM Care Record to support care planning and coordination.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
AI-generated summary

Matthew McManus · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew McManus, who had complex mental health and social care needs, died at the scene after sustaining multiple injuries on 9 November 2020. The report concluded suicide and identified a lack of coordinated care, information sharing, joint assessment and risk planning across the agencies supporting him. It raised concern that without a clear pathway for jointly assessing and coordinating care for adults with complex mental health and social care needs, future deaths may occur.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of agencies to share information and undertake joint assessment and planning
Wider context from the report
“Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. ████████, on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a full appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for-publication-ssab-discretionary-sar-matthew.pdf ”
Source location
Matthew McManus · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the Community Mental Health Framework with named keyworkers, multidisciplinary teams and joined-up personalised care planning.

Verbatim wording from the response
“I would like to assure you that we are, through the development and implementation in local areas of the Community Mental Health Framework (CMHF), working to improve the way people with mental health conditions access joined-up support across health and social care, as well other parts of local systems. I would also like to assure you that more broadly we are bringing a broad range of local services closer together through the Health and Care Act 2022 and the integrated care systems (ICSs) that were formed as a result.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 14 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate the GM Care Record across Greater Manchester health and mental health providers, GPs and hospitals to share information for care coordination.

Verbatim wording from the response
“Additionally, Greater Manchester has accelerated use of the GM Care Record (GMCR) to support data sharing between health and care professionals across the region. It now means that all professionals involved in a patient’s care can share vital information across different organisations, settings and localities. As well as informing clinical decision making at the point of care, the GMCR is also being further enhanced to support joined up care planning and coordination through a range of clinical use cases. GMCR is now active between the two GM mental health trusts, GPs, and the hospital trusts within Greater Manchester. The inclusion of social care data feeds is also underway to further support care planning and coordination. Access to the GMCR can be made available to all relevant organisations that would have a requirement to access data, i.e.”

Source location
Response from Greater Manchester Combined Authority
Page 2 · response
Published 14 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Add social care data feeds to the GM Care Record to support care planning and coordination.

Verbatim wording from the response
“Additionally, Greater Manchester has accelerated use of the GM Care Record (GMCR) to support data sharing between health and care professionals across the region. It now means that all professionals involved in a patient’s care can share vital information across different organisations, settings and localities. As well as informing clinical decision making at the point of care, the GMCR is also being further enhanced to support joined up care planning and coordination through a range of clinical use cases. GMCR is now active between the two GM mental health trusts, GPs, and the hospital trusts within Greater Manchester. The inclusion of social care data feeds is also underway to further support care planning and coordination. Access to the GMCR can be made available to all relevant organisations that would have a requirement to access data, i.e.”

Source location
Response from Greater Manchester Combined Authority
Page 2 · response
Published 14 February 2022
Open published response
2 Feb2022
Dorset
Concerns raised1
1. Failure to ensure PPNs reach GPs for Dorset Council residents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Review PPN-sharing processes with Dorset and BCP Adult Social Care partners to identify safeguarding risks and consistency improvements.
  Stated by Dorset PoliceStated completed
2. Action
  Conduct a further review with Health and Social Care partners of PPN-sharing processes, using national best practice to identify improvements.
  Stated by Dorset PoliceStated planned
3. Action
  Review current PPN-sharing processes with Dorset Police and BCP Council to identify improvements.
  Stated by Dorset CouncilStated completed
1. Action
  Amend Dorset Police and Dorset Council PPN-sharing processes to align with BCP processes.
  Stated by Dorset CouncilStated planned
2. Action
  Fund and recruit additional MASH staff to support sharing PPNs with GPs, with recruitment planned by the end of May 2022.
  Stated by Dorset CouncilStated planned
3. Action
  Meet with Dorset Police, BCP and health partners, including GP safeguarding leads, to discuss PPN-sharing processes and improvements.
  Stated by Dorset CouncilStated planned
4. Action
  Seek approval to align a partnership review of Adult MASH PPN sharing with the Children’s MASH review.
  Stated by Dorset CouncilStated planned
5. Action
  Amend the Adult Access Team process to forward PPNs to relevant agencies regardless of Adult Social Care involvement.
  Stated by Dorset CouncilStated completed
Respondent positions 2
1. Position
  Police cannot share PPNs with GPs directly because it lacks access to the Dorset Care Record.
  Stated by Dorset PoliceUnable to act
1. Position
  Dorset Council Adult Social Care staff will be responsible for sharing PPNs with GPs using the Dorset Care Record.
  Stated by Dorset PoliceRedirects responsibility
AI-generated summary

Carol Patricia Cole · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Carol Patricia Cole was found collapsed and unresponsive at home on 15 May 2020 after being prescribed medication and having a history including depression, unstable personality disorder and previous overdoses. The inquest concluded that her death was suicide. Concerns were raised that processes for sharing Public Protection Notices in the Dorset Council area may have resulted in the GP not receiving information about concerns regarding her mental health, creating a missed opportunity for assessment, support or treatment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure PPNs reach GPs for Dorset Council residents
Wider context from the report
“iii. In Dorset there are 2 Local Authorities that cover the County, BCP Council and Dorset Council. If MASH receive a PPN about a resident in the BCP Council area the current arrangement is that MASH send the PPN directly to the GP as required. If they receive a PPN about a resident in the Dorset Council area the current process is that they do not send it directly to the GP but send it directly to the Dorset Adult Access team at Dorset Council, who will then send it to the GP. iv. At the time of her death Carole resided within the Dorset Council area. A PPN was submitted to MASH regarding Carole on 25.4.20 which raised concerns regarding her mental health. The MASH team determined the PNN should be shared with the Dorset Adult Access team to share with the GP in line with the process. v. At the Inquest the representative from the GP surgery confirmed there was no record of the PNN being received by them, which led to a missed opportunity for Carole to be assessed by her GP. vi. The process currently in place, which I understand has been agreed by both Dorset Council and Dorset Police, of preventing the MASH team from sending the PNN directly to the GP, may result in the GP not being informed of the contents of the PPN which may result in a person not receiving an assessment, support or treatment. I am not aware of a reason why the MASH team cannot send it directly to the GP, as they do for those residents in BCP council area, to avoid such missed opportunities to take action which may lead to a future death. 2. I have concerns with regard to the following: i. There could be missed opportunities to share PPNs relating to residents within the Dorset Council area with agencies or professionals due to the current processes in place between Dorset Police and Dorset Council which could lead to a future death. I therefore request that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. ”
Source location
Carol Patricia Cole · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review PPN-sharing processes with Dorset and BCP Adult Social Care partners to identify safeguarding risks and consistency improvements.

Verbatim wording from the response
“You therefore requested that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area.”

Source location
2022-0033-Response-from-Dorset-Police_Published
Page 1 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a further review with Health and Social Care partners of PPN-sharing processes, using national best practice to identify improvements.

Verbatim wording from the response
“Identification of this risk has prompted a further review with Health partners which is scheduled to commence on 12 April 2022. Police, Health and Social Care will work together to review the current process, what is working well and where improvements can be made based on national best practice from other areas.”

Source location
2022-0033-Response-from-Dorset-Police_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review current PPN-sharing processes with Dorset Police and BCP Council to identify improvements.

Verbatim wording from the response
“The request was made that Dorset Police and Dorset Council review their current processes in place regarding the sharing of PPNs by MASH, especially to General Practitioners for the residents within the Dorset Council area. We reviewed the current PPN process with Dorset Police and Bournemouth, Christchurch and Poole (BCP) Council between 16/02/2022 and 16/03/22. This involved members of the operational management team at Dorset Council and Bournemouth, Christchurch and Poole (BCP) Council and Dorset Police Public Protection Unit meeting to analyse current steps in the process. This identified the following areas of improvement:”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 1 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend Dorset Police and Dorset Council PPN-sharing processes to align with BCP processes.

Verbatim wording from the response
“i) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have immediate impact on the current process, Dorset Council will fund additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022.”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Fund and recruit additional MASH staff to support sharing PPNs with GPs, with recruitment planned by the end of May 2022.

Verbatim wording from the response
“i) Amend the current process of sharing PPNs between Dorset Police and Dorset Council to align with BCP processes. This requires work to ensure the MASH has adequate capacity and access to up-to-date information about a person’s GP. To have immediate impact on the current process, Dorset Council will fund additional staffing resources to MASH to assist with the sharing of PPNs to GPs to allow time for a wider system review of MASH to be completed. The plan is to complete recruitment by end of May 2022.”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Meet with Dorset Police, BCP and health partners, including GP safeguarding leads, to discuss PPN-sharing processes and improvements.

Verbatim wording from the response
“ii) A meeting has been arranged between Dorset Council, Dorset Police MASH, BCP and health partners including GP safeguarding leads in April 2022 to discuss current PPN sharing processes, including what is working well and areas for improvement. This was the earliest opportunity to do so, so that all parties could be represented.”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Seek approval to align a partnership review of Adult MASH PPN sharing with the Children’s MASH review.

Verbatim wording from the response
“iii) Share learning from the Regulation 28 report at Dorset’s Safeguarding Adult Review in April 2022 and seek approval to align a full partnership review of PPN sharing within Adult MASH with the Children’s MASH review which will take place in July 2022.”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Amend the Adult Access Team process to forward PPNs to relevant agencies regardless of Adult Social Care involvement.

Verbatim wording from the response
“iv) Amend Dorset Council’s internal process so that the Adult Access Team forward PPNs to relevant agencies or professionals regardless of whether the person is known or not known to Adult Social Care. This was immediately actioned and implemented on 25/02/22.”

Source location
2022-0033-Response-from-Dorset-Council_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Police cannot share PPNs with GPs directly because it lacks access to the Dorset Care Record.

Verbatim wording from the response
“The review also identified that for the Police to carry out the sharing of PPNs to GPs there would be a requirement for Police to have access to the Dorset Care Record which it currently does not have.”

Source location
2022-0033-Response-from-Dorset-Police_Published
Page 2 · response
Published 4 February 2022
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Dorset Council Adult Social Care staff will be responsible for sharing PPNs with GPs using the Dorset Care Record.

Verbatim wording from the response
“On 28 March 2022, it was agreed that Dorset Council will fund a member of staff from Adult Social Care to co-locate with Dorset Police in the MASH. This role would be responsible for sharing with GPs and have access to the Dorset Care Record. In the interim I am aware that the Dorset Adult Access Team promptly streamlined their working practices in February 2022 to overcome the issue that resulted in the failure to share the PPN with the GP in the case of Ms Cole.”

Source location
2022-0033-Response-from-Dorset-Police_Published
Page 2 · response
Published 4 February 2022
Open published response
26 Nov2021
Dorset
Concerns raised1
1. Lack of accessibility to records held by different healthcare 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 2
1. Action
  Convert ambulance and other pre-hospital information into PDF documents stored in the hospital electronic record for Emergency Department access.
  Stated by Yeovil District HospitalStated completed
2. Action
  Advance the Shared Care Records programme to enable information sharing across integrated care systems and, subsequently, regions and nationally.
  Stated by NHS EnglandStated in progress
AI-generated summary

Felicity Jane Clough · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Felicity Jane Clough was taken to hospital on 24 November 2019 after being prescribed Tramadol, discharged during the early morning, and later found collapsed and unresponsive in a field. The concerns included limited information-sharing between healthcare trusts and police forces, and the failure to consistently review paramedic records containing potentially critical information at Yeovil District Hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of accessibility to records held by different healthcare trusts
Wider context from the report
“i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts. I would request consideration is given to the sharing of records between healthcare trusts. ”
Source location
Felicity Jane Clough · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Convert ambulance and other pre-hospital information into PDF documents stored in the hospital electronic record for Emergency Department access.

Verbatim wording from the response
“I can confirm that the Emergency Department at Yeovil District Hospital has put measures in place that will mitigate the risk of staff not accessing pre-hospital information for those patients that attend the department and in particular those brought in by ambulance. I have included a copy of the action log regarding this with this correspondence.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 12 · response
Published 29 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advance the Shared Care Records programme to enable information sharing across integrated care systems and, subsequently, regions and nationally.

Verbatim wording from the response
“NHS England have a programme of work – the Shared Care Records initiative – which is seeking to rectify this.”

Source location
Response from Secretary of State for Health and Social Care, Minister for Crime and Polici
Page 7 · response
Published 29 November 2021
Open published response
17 Nov2021
Birmingham and Solihull
Concerns raised1
1. Lack of a clear process for cascading relevant MARAC information to involved officers
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 5
1. Action
  Publish a national circular to chief officers raising the concerns and recommending that forces consider local MARAC information-recording and sharing practices.
  Stated by College of PolicingStated planned
2. Action
  Centralise MARAC coordination and administration and introduce trained minute takers, MARAC coordinators and a regional lead.
  Stated by West Midlands PoliceStated completed
3. Action
  Review links between the MARAC system and wider police systems and departments to improve information capture and sharing.
  Stated by West Midlands PoliceStated in progress
1. Action
  Maintain a regional MARAC Operating Protocol governing agency engagement and information sharing.
  Stated by West Midlands PoliceStated completed
2. Action
  Provide ongoing regional MARAC training and require intensive training before minute takers work alone.
  Stated by West Midlands PoliceStated completed
Respondent positions 1
1. Position
  West Midlands Police and other forces are responsible for local policies and practices governing MARAC information recording and dissemination.
  Stated by College of PolicingRedirects responsibility
AI-generated summary

Trevor Alton SMITH · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Trevor Smith died after being shot by a member of a police armed response unit during an attempted arrest at his home. The principal concerns were that information about an alleged previous overdose was not recorded or cascaded to the firearms team, and that officers were confused about CPR rescue breaths and coordination during resuscitation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a clear process for cascading relevant MARAC information to involved officers
Wider context from the report
“1. MARAC Information: Before firearms officers deployed to Mr Smith’s address a MARAC (Multi Agency Risk Assessment Conference) meeting took place on 12/03/19 when agencies shared information about the alleged victim of domestic violence and the alleged suspect Mr Smith. The evidence at the inquest confirmed that it was likely that Birmingham and Solihull Mental Health NHS Foundation Trust shared information that Mr Smith had taken an overdose of medication in January 2019. This information was not minuted by WMP nor reported back to the Senior Investigating Officer or the firearms team. As a result, they were unaware of this information and Mr Smith was not declared EMD (emotionally and mentally distressed). The evidence at the inquest confirmed that actions would have been the same even had Mr Smith been declared EMD. It was clear during the evidence that there was no clear guidance/process for accurately recording information at MARAC by WMP and no clear process for ensuring relevant information is cascaded to officers involved in the case. Consideration should be given to updating existing processes and policies to ensure accurate and relevant information is cascaded from MARAC. 2. CPR coordinator. The evidence at the inquest confirmed that officers appeared confused about the need for rescue breaths to be given to Mr Smith during resuscitation. The inquest also heard how appointing one person to coordinate the resuscitation (if there are sufficient personnel) would have been of benefit. Consideration should be given to amending policies and procedures and training to ensure one person is allocated to coordinate CPR if it is required. ”
Source location
Trevor Alton SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish a national circular to chief officers raising the concerns and recommending that forces consider local MARAC information-recording and sharing practices.

Verbatim wording from the response
“Police forces implement localised policies and practice in terms of the recording and dissemination of intelligence. The College Authorised Professional Practice for Armed Policing (APP-AP) Armed policing (college.police.uk) provides guidance to firearms commanders in respect of information and intelligence gathering, and the importance of considering the potential that the subject of an operation may be emotionally or mentally distressed. I consider the relevant APP-AP content to be appropriate. My Armed Policing Team has, however, agreed with the National Police Chiefs’ Council (NPCC) portfolio lead for armed policing (Chief Constable Simon Chesterman), to publish a national circular for dissemination to chief officers.”

Source location
2021-0387-Response-from-College-of-Policing_Published
Page 2 · response
Published 19 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Centralise MARAC coordination and administration and introduce trained minute takers, MARAC coordinators and a regional lead.

Verbatim wording from the response
“The agency responsible for minute-taking and coordination in this case was Coventry Haven, who were commissioned to perform this duty up until the 31st March 2019, two weeks after the MARAC meeting in question took place. It was after this time that WMP took responsibility for the coordination and administration of all seven local authority areas, including Solihull, from 1st April 2019.”

Source location
2021-0387-Response-from-West-Midlands-Police_Published
Page 1 · response
Published 19 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review links between the MARAC system and wider police systems and departments to improve information capture and sharing.

Verbatim wording from the response
“However, as all MARAC information is recorded on a system separate to Connect, which is where the vast majority of Police information is stored, this impacts upon transparency and speed of information sharing.”

Source location
2021-0387-Response-from-West-Midlands-Police_Published
Page 2 · response
Published 19 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain a regional MARAC Operating Protocol governing agency engagement and information sharing.

Verbatim wording from the response
“Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.”

Source location
2021-0387-Response-from-West-Midlands-Police_Published
Page 3 · response
Published 19 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide ongoing regional MARAC training and require intensive training before minute takers work alone.

Verbatim wording from the response
“Response: There is a regional MARAC Operating Protocol which has been in place since 1st April 2019. It governs WMP and wider agency engagement with the MARAC process and offers clear guidance on what is expected of them and what they can expect of Information Sharing within the process. Further, the MARAC Coordination team are responsible for ongoing MARAC training across the region which ensures that partners engaging in the process have staff trained and prepared to do so. In addition all MARAC minute takers are intensively trained when in role and are not permitted to take minutes alone until training is complete to the satisfaction of the local MARAC Coordinator.”

Source location
2021-0387-Response-from-West-Midlands-Police_Published
Page 3 · response
Published 19 November 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
West Midlands Police and other forces are responsible for local policies and practices governing MARAC information recording and dissemination.

Verbatim wording from the response
“The first concern raised in the report relates to the MARAC process undertaken by West Midlands police, and specifically that potentially significant information disclosed at a meeting to discuss Mr Smith was not effectively cascaded to the SIO or firearms team prior to the policing operation to arrest him. I understand that West Midlands police has provided a response to your concern.”

Source location
2021-0387-Response-from-College-of-Policing_Published
Page 2 · response
Published 19 November 2021
Open published response
16 Nov2021
Inner North London
Concerns raised1
1. Failure to communicate safety-critical mental-health and medical information to relevant agencies
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.
AI-generated summary

Joseph MARTIN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Joseph Martin approached Metropolitan Police Service officers near Westminster Bridge on 3 June 2021, after concerns had been raised about his mental health and safety. The inquest found that he was suffering a psychotic relapse at the time of his death, but the exact circumstances were unclear. The report raised concerns that important information about his mental health and vulnerability was not shared between police forces and that individual errors and wider system weaknesses failed to provide a safety net.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate safety-critical mental-health and medical information to relevant agencies
Wider context from the report
“Joseph Martin was reported as a person of concern to the PSNI on 28 May 2021 by staff at the hostel where he lived. His consultant psychiatrist called the PSNI on 1 June 2021 and raised very grave concerns about what he described as a vulnerable missing person, explaining that Mr Martin had suffered a psychotic relapse, and voicing significant worries about his safety and about the safety of others. The doctor re-iterated and reinforced all of this on 2 June, when the PSNI rang him to say that they did not consider any further action required. He was told that it would be looked into further. However, when the MPS contacted the PSNI on the morning of 3 June, these concerns were not relayed. I was told that the contacts had not been noted on the missing person report or the occurrence log by the investigating officer. Then the officer tasked with calling the MPS back did not conduct a search of all records, and so did not see the contacts. Finally, when a PSNI officer rang Mr Martin’s mother to say that her son had approached MPS officers, and she told the officer how very worried she was about her son’s mental health, the officer did not then call the MPS back. I appreciate that by then he thought that Mr Martin was going to go to hospital, but Mr Martin had not been detained and in any event the hospital needed the crucial medical history that had been given. There were individual errors, and more significantly a system that does not seem to have provided a safety net. ”
Source location
Joseph MARTIN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Oct2021
Manchester City
Concerns raised1
1. Failure of communication between mental health and primary care professionals to support assessment of presentation and risk changes
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 3
1. Action
  Employ physical-health nurses within CMHTs to complete annual physical-health assessments and communicate results to GPs, with Trust monitoring.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
3. Action
  Audit CMHT use of care-record interfaces for communication with GPs and share the audit and resulting action plan with the Trust audit committee.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
AI-generated summary

Jude Daryl Lloyd · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of communication between mental health and primary care professionals to support assessment of presentation and risk changes
Wider context from the report
“g. There were a number of missed opportunities for the CMHT to assess changes in his presentation and risk profile due to a lack of appropriate communication between mental health and primary care professionals. ”
Source location
Jude Daryl Lloyd · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Employ physical-health nurses within CMHTs to complete annual physical-health assessments and communicate results to GPs, with Trust monitoring.

Verbatim wording from the response
“There is a physical health nurse employed within each of the CMHT’s who undertakes a physical health assessment, based on the Lester Tool, as a minimum annually. The Lester Tool helps frontline staff make assessments of cardiac and metabolic health, helping to cut mortality for people with mental illnesses. Results of these assessments and any investigations are communicated to the GP via letter. The completion of these physical health assessments and communication with the GP are monitored by the Trust.”

Source location
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 2 · response
Published 13 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.

Verbatim wording from the response
“Going forward the Trust physical health care group will reinstate a Diabetes workstream to continue to improve the management of people with diabetes across the Trust. We will ensure that the Diabetes workstream have oversight of compliance with training about diabetes management and are involved in the management and risk analysis incidents around diabetes care. We intend to make the care of someone with diabetes as one of our main quality improvement care projects in the organisation that will be led by the physical health care group who will act as the lead for this. This will involve further enhancing the connections and communication with primary care and will involve the new primary healthcare practitioners, which are new joint posts working across the new primary care networks and GMMH.”

Source location
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 2 · response
Published 13 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit CMHT use of care-record interfaces for communication with GPs and share the audit and resulting action plan with the Trust audit committee.

Verbatim wording from the response
“GMMH services across Manchester have access to the GM care record that means they can check when someone last saw their GP. The CMHT’s also, as outlined in the Trust RCA report access Graphnet, an interface system between Primary and Secondary Care. Any results or investigations carried out by GMMH staff are uploaded to Graphnet as well as being sent to the GP in a letter. The CMHT staff can access the system to see any results uploaded by the GP. The CMHT manager has carried out audits to give assurance that this system is being used to communicate with the GP’s. The audit and any resulting actions plan will be shared at the Trust audit committee.”

Source location
2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 5 · response
Published 13 October 2021
Open published response
27 Aug2021
Manchester South
Concerns raised1
1. Lack of coordinated information sharing between professionals involved in mental health care
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.
AI-generated summary

Fadhia SEGULEH · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Fadhia Seguleh was receiving treatment for anxiety and depression when she was found unresponsive, attached to a ligature at her home on 24 February 2021. The concerns included fragmented care and inadequate information sharing between NHS mental health services, her GP and private therapy provider, telephone-only mental health assessments during Covid, and her attending A&E alone during a previous mental health crisis without family input.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of coordinated information sharing between professionals involved in mental health care
Wider context from the report
“1. The inquest heard evidence that she was being treated by the NHS Mental Health Trust, GP and through private therapy provided by her employer. As a consequence, the professionals treating her did not have a full picture of disclosures made by her and professionals operated in silos. There was no protocol in place for information sharing between those involved and no policy to guide appropriate steps to obtain information. A query raised with the GP would have enabled a clearer picture of the issues to be held by the private provider. Information sharing would have provided a more rounded understanding of risks. The operation in silos meant that the treatment plan put in place by the mental health team including medication was not fully understood by the GP and was altered following a consultation between the GP and Fadhia. Information sharing between agencies would have allowed for a more detailed assessment of risk in the situation. ”
Source location
Fadhia SEGULEH · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to share medical information with other agencies

Concerns raised1

Failure to share crucial clinical information between healthcare organisations

Concerns raised1

Inadequate timely communication and follow-up action between agencies

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of agencies to share information and undertake joint assessment and planning

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

Concerns raised1

Failure to ensure PPNs reach GPs for Dorset Council residents

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of accessibility to records held by different healthcare trusts

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

Concerns raised1

Lack of a clear process for cascading relevant MARAC information to involved officers

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

Actions described in response 4

Respondent positions 1

Actions described in response 3

Actions described in response 8

Respondent positions 2

Actions described in response 2

Actions described in response 5