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 North London
Concerns raised1
Failure to verify treatment information with external mental health service providers
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.1
Action
Distribute guidance to City and Hackney clinical staff on contacting external mental health providers.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 July 2017.
Inner North London
Concerns raised1
Absence of a clearly understood system for sharing relevant community patient information and escalating care-quality concerns between the Community District Nursing Team and partner 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.
Birmingham and Solihull
Concerns raised1
Failure to share and access mental health records effectively between organisations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Gloucestershire
Concerns raised1
Lack of information sharing between agencies providing support services
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.
Birmingham and Solihull
Concerns raised1
Failure to communicate relevant clinical information between hospitals
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.4
Action
Conduct meetings between QEHB and RHH clinical staff to identify communication and referral-system improvements.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Action
Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.
Stated by the Dudley Group NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Action
Deliver the agreed cross-Trust action plan to address identified safety concerns.
Stated by the Dudley Group NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 October 2016.
Action
Conduct cross-hospital meetings to identify communication and patient-management improvements following the clinical incident.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 October 2016.
Inner South London
Concerns raised2
Failure of detained organisations to pass risk information consistently between one another
Lack of clear responsibility for passing or seeking relevant 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.3
Action
Provide AMHP guidance on confidential information sharing with GP practices and prison healthcare.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Work with NHS providers and Hampshire Constabulary to review information sharing after joint police-custody assessments.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Establish a governance framework monitoring police-custody assessment outcomes, information sharing, relative communication and AMHP training records.
Stated by Hampshire County Council and Portsmouth City CouncilStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Birmingham and Solihull
Concerns raised1
Failure to highlight essential patient information during transfers between care homes
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Implement an additional action plan and timetable responding to the inquest findings.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Continue embedding all organisational policies and procedures at Aran Court.
Stated by Avery Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Raise the transfer and discharge communication lessons from the incident in a forthcoming quarterly Safety 1st bulletin shared across Amore Care Homes.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Highlight to home staff the requirement to complete Form AM32 Transfer Discharge records, including prompts for key information such as PCA behaviour.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Comprehensive pre-admission and transfer documentation is considered sufficient to identify relevant clinical risks when completed correctly.
Stated by Avery Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing admission and handover documents were considered sufficient to capture known risks during transfers when completed appropriately.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
System-wide direction on identifying essential transfer information is directed to the governing body, such as the regulator or relevant health department.
Stated by Priory GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The commissioning organisation should ensure receiving care homes can meet transferred patients’ needs; the Care Quality Commission may comment on this.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure of information-sharing between trusts
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised1
Failure to pass requested further information back to the requesting agency or professional
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Yorkshire (Western)
Concerns raised1
Failure of agencies to obtain information from previously involved 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.
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.
