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.
Inner South London
Concerns raised2
Failure to identify all children when sharing risk information
Failure of case-record access and handover of key domestic-violence risk information
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to ensure accurate and complete cross-organisation safeguarding communications
This report raised 16 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.5
Action
Conduct an independent external Lessons Learned Review of safeguarding and conduct handling, including information management, risk assessment, casework and inter-church sharing.
Stated by Diocese of London and Lambeth PalaceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2021.
Action
Design and implement improved systems for capturing, triaging, recording, assessing and appropriately sharing safeguarding and conduct information.
Stated by Diocese of London and Lambeth PalaceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021.
Action
Deliver safeguarding-specific GDPR training and strengthen recording, auditing and lawful, proportionate information-sharing practice.
Stated by Diocese of London and Lambeth PalaceStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2021.
Action
Implement formal information-sharing protocols and agreements for safeguarding information with relevant statutory, faith and partner organisations.
Stated by Diocese of London and Lambeth PalaceStated plannedThe respondent said that this action was planned when they made their response on 15 July 2021.
Action
Collaborate with the Church of England to create and implement information-sharing and unresolved-concern escalation processes.
Stated by CSSAStated plannedThe respondent said that this action was planned when they made their response on 15 July 2021.
Manchester South
Concerns raised1
Poor inter-agency information sharing
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.
Cambridgeshire and Peterborough
Concerns raised1
Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies
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
Establish a working group to develop a national approach to sharing medication-safety information with community pharmacies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 2 June 2021.
Action
Continue campaigning for community-pharmacy access to and sharing of patient health records.
Stated by Royal Pharmaceutical SocietyStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2021.
Action
Publish a policy and position statement on patient health records.
Stated by Royal Pharmaceutical SocietyStated completedThe respondent said that this action was complete when they made their response on 2 June 2021.
Action
Publish guidance on keeping patients safe when they transfer between care providers.
Stated by Royal Pharmaceutical SocietyStated completedThe respondent said that this action was complete when they made their response on 2 June 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
NHS and CAMHS organisations are responsible for making changes to prevent deaths involving pharmacy communication and medication safety plans.
Stated by Royal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Direct action is outside the remit because the organisation does not operate pharmacies or set standards and guidance for pharmacy operators.
Stated by Company Chemists’ Association LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
Changing information-sharing and care-planning processes cannot be undertaken because the relevant organisations lack legislative authority.
Stated by Company Chemists’ Association LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to communicate patients’ clinical condition and observations between clinicians when telephone advice is sought
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
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Scope improvements to recording patient information for patients needing specialist advice while off site.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Work with the Norse supplier to transition to the system’s latest version and additional features.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
Manchester South
Concerns raised1
Lack of a clear multi-agency strategy for supporting complex cases
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.1
Action
Establish two externally facilitated task-and-finish groups to review Section 42 and MAARS/TAA processes within the multi-agency safeguarding rewrite.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 May 2021.
Manchester South
Concerns raised1
Lack of clear inter-agency information-sharing arrangements for complex care
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.2
Action
Continue driving health and social care integration by removing data-sharing barriers and enabling joint decision-making.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2021.
Action
Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 29 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing shared-system arrangements are considered effective for communicating current information between organisations involved in complex patient discharges.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The relevant Safeguarding Adults Board may undertake a review to identify learning and improvement actions across local agencies.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Developing policy and procedures for integrated care and communication is outside the regulator’s direct remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Manchester South
Concerns raised1
Lack of specific rules allocating agency responsibilities for conveying information when vulnerable patients are sent home from urgent care without admission
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Because the patient was technically not admitted, the Trust did not need to invoke its hospital discharge process.
Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to pass relevant incident and vulnerability information to ambulance and hospital staff
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.1
Action
Improve officers’ sharing of vital incident information with colleagues, ambulance crews and medical staff.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 30 December 2020.
Northamptonshire
Concerns raised1
Failure of primary and secondary care electronic patient systems to share allergy information
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.
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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.
