Recurring concern
Unreliable inter-agency information sharing for coordinated care
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Request correctionFirst reported 29 May 2013•Latest report 15 Jun 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of multi-agencies to share patients' past medical history, including previous falls history
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of structured and direct information sharing between hospital and ambulance services
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 concernsEach 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
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Action
Implement the SBAR communication framework for clinical handovers.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Develop and seek regional agreement for a maternity-specific SBAR handover model.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Implement the maternity-specific SBAR handover model across the EMAS footprint.
Stated by East Midlands Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.
Stated by Health Services Safety Investigations Body
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Position
Operational concerns are for the involved NHS trusts to address.
Stated by Department of Health and Social Care -
Position
HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.
Stated by Department of Health and Social Care
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Concerns raised1
Limited information sharing between adult safeguarding board members
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 concernsEach 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
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Action
Update TARGet meeting terms of reference to strengthen safeguarding-partner information sharing and multi-agency risk assessment and management planning.
Stated by Trafford Safeguarding Board
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Concerns raised1
Failure to inform the relevant HTT of consent to contact support persons
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of the emergency information-relay system between birthing centres and hospitals
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 concernsEach 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
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Action
Update the Standard Operating Procedure and Clinical Directive to require clinicians to identify time-critical transfers and prioritise qualifying inter-facility calls as Category 1.
Stated by South Central Ambulance Service NHS Foundation Trust -
Action
Issue a reminder to Emergency Departments and birthing units across the South Central area about the process for requesting time-critical transfers.
Stated by South Central Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure to communicate vital transfer information to patients, families and receiving clinicians
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide PER staff with relevant previous self-harm and suicide risk information
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Use the next custody newsletter to reinforce PER completion, inspection, warning-page, envelope, risk-marker and external-information responsibilities.
Stated by Hampshire and Isle of Wight Constabulary
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Detention officers completing PERs had access to Hampshire Constabulary systems and the Police National Computer, but not other forces’ internal systems.
Stated by Hampshire and Isle of Wight Constabulary
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Position
Obtaining information from every external agency on every occasion is impracticable, so officers cannot routinely obtain all external data.
Stated by Hampshire and Isle of Wight Constabulary -
Position
Officers must rely on each police force or agency to place relevant information on the national Police National Computer.
Stated by Hampshire and Isle of Wight Constabulary
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Concerns raised1
Failure to ensure effective information exchange during mental health service transfers
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 concernsEach 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
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Action
Amend the transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.
Stated by Mersey Care NHS Foundation Trust -
Action
Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.
Stated by Mersey Care NHS Foundation Trust -
Action
Consider including an audit of transfer processes in the Junior Doctor Audit programme.
Stated by Mersey Care NHS Foundation Trust
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Concerns raised1
Limited information sharing between health professionals to identify service access and need for psychiatric referral
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 concernsEach 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
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Action
Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
Stated by Grosvenor Medical Centre
Data last updated 7 September 2026