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
Distinct published reports
Individual concerns
235
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
492
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social 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
NHS trust106
Ministerial department68
Executive non-departmental public body45
Police force30
Integrated care board24
Type not available20
Healthcare site19
Private limited company15
English county council12
Health-system partnership12
English metropolitan district council11
Executive agency11
English unitary authority9
National policing body8
Health and social care service regulator7
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.
Manchester South
Concerns raised1
Limited information-sharing protocols between probation and partner services
This report raised 18 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.6
Action
Implement mandatory professional registration for Probation Officers to support continuing development, performance and accountability.
Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Establish information-sharing procedures and guidance for agreements with partner agencies, including drug and alcohol services.
Stated by HM Prison and Probation Service and Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Develop a multi-agency public protection system with improved offender-management functionality and information sharing.
Stated by Home OfficeStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Implement a standard operating procedure governing referral, enrolment, clinical-system checks, external risk information, and managerial authorisation for College students.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Establish information-sharing requirements for students, clinical teams, external agencies, and College partners through permissions, risk liaison, and signed partnership agreements.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Establish a controlled generic College email account with defined access, daily checking, welfare and risk escalation routes, and absence cover.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Probation staffing, supervision, referral risk management and information-sharing matters are primarily for the Ministry of Justice to address.
Stated by Greater Manchester PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Most concerns fall to the Ministry of Justice, Home Office and Greater Manchester Police, which will respond to the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Leicester City and South Leicestershire
Concerns raised1
Failure of the Crisis Team procedure to require obtaining relevant risk information from other agencies at assessment
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
Update the Crisis Resolution Home Treatment Team and Mental Health Central Access Point procedures to clarify information-gathering expectations and actions when key professionals cannot be contacted.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 23 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Student Roost is responsible for addressing the first matter of concern; the Trust will respond only to the second matter relevant to it.
Stated by Leicestershire Partnership NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Leicester City and South Leicestershire
Concerns raised1
Failure to communicate historic Child Sexual Exploitation risk between care homes
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East Sussex
Concerns raised1
Failure to reliably transfer key medical information between incompatible systems
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.4
Action
Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.
Stated by Egton Medical Information Systems LimitedStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Action
Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.
Stated by Egton Medical Information Systems LimitedStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Stated by Egton Medical Information Systems LimitedStated in progressThe respondent said that this action was in progress when they made their response on 25 March 2024.
Action
Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.
Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 25 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.
Stated by Egton Medical Information Systems LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
EMIS cannot control whether prisons request medical records through GP2GP or a manual process.
Stated by Egton Medical Information Systems LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.
Stated by The Phoenix Partnership (Leeds) LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to use regular MDTs to share and understand multi-agency information
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 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.4
Action
Embed multi-agency review processes after the death of someone experiencing homelessness or rough sleeping.
Stated by Ministry of Housing, Communities and Local GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Action
Coordinate Changing Futures pilots to improve joined-up local support for people experiencing multiple disadvantages.
Stated by Ministry of Housing, Communities and Local GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Action
Support NICE guidance improving access to coordinated, multidisciplinary health and social care for people experiencing homelessness.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 March 2024.
Action
Continue transforming community mental health services toward personalised care planning, named key workers and multidisciplinary assessment and support.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 20 March 2024.
Birmingham and Solihull
Concerns raised1
Failure to coordinate interagency release management and share critical information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.20
Action
Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.
Stated by G4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.
Stated by G4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
Stated by G4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.
Stated by G4SStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Review the Prison In-reach and CMHT interaction process, complete a gap analysis and develop a plan to strengthen continuity of care.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Implement an improved referral and discharge procedure through the updated standard operating protocol.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Approach SystemOne to discuss the feasibility of adding a local field for community mental health team information.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Hold formal admission handovers and pre-release meetings with transferring mental-health teams or prisons and relevant agencies.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Continue updating ViSOR records for each individual so information can be shared across agencies.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Visit managed offenders after prison release regardless of their MAPPA process status.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
Stated by West Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
Stated by G4SOutside remitThe respondent said that this matter was outside its role or authority.
Position
HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
Stated by G4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.
Stated by G4SUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Issues concerning information sharing on NDelius should be addressed to HMPPS.
Stated by G4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A unified prison interagency IT system cannot be implemented because the Health Board lacks the necessary power.
Stated by Swansea Bay University Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.
Stated by Swansea Bay University Local Health BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Poor communication and fragmented input across trusts
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.3
Action
Update the GM Care Record webpage and relaunch the system to raise awareness of its information-sharing capabilities.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Update GM Care Record eLearning to support access to and use of the system.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide additional training on how to access and use the GM Care Record.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Inner South London
Concerns raised1
Lack of contact details for neighbouring psychiatric liaison and crisis mental health teams
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing NHS Service Finder and website directories provide professionals with current neighbouring mental health service contact details and referral information.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to provide the GP with sufficient information about pressure-ulcer deterioration
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.2
Action
Discuss with the nursing team the importance of following up concerns and actions directly with GPs rather than relying on care-home staff.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
Action
Follow up actions establishing clear responsibility for escalating wound-care concerns to GPs.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The registered GP had access to current District Nursing information through the shared electronic record, contrary to the concern that information was unavailable.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The GP could reasonably expect tissue viability specialists to lead pressure-ulcer treatment and advise the GP if treatment became ineffective.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
North Wales (East and Central)
Concerns raised2
Failure to share relevant clinical information between the Health Board and out-of-area psychiatric facilities
Lack of agreed minimum information-sharing standards between the Health Board and private psychiatric facilities
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Action
Monitor compliance with the standard operating procedure through local and divisional Putting Things Right meetings.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 12 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The concern that Elysium failed to share discharge information is factually incorrect; Betsi was informed by telephone and emailed relevant records.
Stated by Elysium Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The described processes did not create a future-death risk for Elysium because information was provided and Betsi had time to intervene.
Stated by Elysium Healthcare LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.
Stated by Elysium Healthcare LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Pin
Get email alerts
Request correction
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.
