Recurring concern

Unreliable inter-agency information sharing for coordinated care

First to latest report 29 May 2013 — 15 Jun 2026

Reports that mention this concern
212
Times this concern has been raised
235
Stated actions linked to this concern
492

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.

What is 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 and published responses 212 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Mid Kent and Medway

    AI-generated summary

    Ricky Anderson · 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

    Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan before his death.

    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 inform the GP of hospital admissions involving primary care

    Wider context from the report

    “(1) It was established in evidence at the inquest that practitioners from the Kent and Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson's GP of his involvement with primary care on either occasion he was admitted to hospital, resulting in him not being able to obtain a further supply of medication without the intervention of his family ”

    Source location

    Ricky Anderson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Worcestershire

    AI-generated summary

    Dana Louise Baker · 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

    Dana Louise Baker was a looked after child whose foster placement broke down, after which she stayed with an adult friend and the following day hanged herself in a public place. The principal concerns were inadequate knowledge, understanding and communication between agencies, and the confidential handling of Individual Management Reviews, which prevented agencies from understanding areas of mutual concern.

    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 knowledge and understanding between agencies

    Wider context from the report

    “(1) As outlined in the IMR's, the Serious Case Review and the draft Overview Report there was a lack of knowledge and understanding as between various agencies involved with Dana and inadequate communication between them. ”

    Source location

    Dana Louise Baker · Prevention of Future Deaths report
    Page 1 · 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

    Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.

    Verbatim wording from the response

    “The sharing of IMRs between agencies on the Panel has always been a key element of the SCR process and the more collaborative 'systems approach'”

    Source location

    2014-0242-Response-by-Safeguarding-Children-Board
    Page 2 · response
    Published 29 May 2014

    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 Case Reviews using the Social Care Institute for Excellence and Significant Incident Learning Process models.

    Verbatim wording from the response

    “In response to this guidance a number of models have been developed nationally, including the Social Care Institute for Excellence (SCIE) and the Significant Incident Learning Process (SILP) models. WSCB has already undertaken Case Reviews using both of these models and the feedback to date has been positive. Whilst the process can be challenging for practitioners and managers, they also welcome the opportunity for closer engagement, reflection and learning.”

    Source location

    2014-0242-Response-by-Safeguarding-Children-Board
    Page 2 · response
    Published 29 May 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026