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.
Derby and Derbyshire
Concerns raised1
Lack of shared policies, guidance and understanding about information relevant for sharing between 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 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.7
Action
Use the Perinatal Mental Health Service advice line for consultation and proactively share relevant contextual information about patients already receiving its care.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Develop and circulate an infographic explaining the advice line, appropriate use, and information to share, with practical examples for Health Visiting staff.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Update Health Visiting Service standard operating procedures to formalize information-sharing expectations and use of the Perinatal Mental Health Service advice line.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Add contextual-information-sharing guidance to the electronic referral document for professionals.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Practice does not consider a policy or guidance on relevant information sharing capable of assisting with this concern.
Stated by Sett Valley Medical CentreNo action considered necessaryThe respondent said that no further action was needed.
South Yorkshire (Western)
Concerns raised1
Failure to include recent s136 detention information in force control communications
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.
Suffolk
Concerns raised1
Lack of a mechanism for police to communicate consented mental-health risk information to medical or mental health care providers
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
Require the Contact and Control Room to confirm NHS 111 Option 2 was signposted or contacted before closing a CAD incident.
Stated by Suffolk ConstabularyStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Action
Continue consulting partner agencies to evaluate NHS 111 Option 2’s operability, reliability, staff knowledge, and training needs.
Stated by Suffolk ConstabularyStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Action
Continue cooperating with partner agencies and sharing relevant information under applicable arrangements to support timely clinically led crisis assessment when suicide risk is identified.
Stated by Suffolk County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Existing NHS 111 Option 2 clinical pathways provide an adequate mechanism for raising adult mental health concerns below statutory thresholds.
Stated by Suffolk ConstabularyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
NSFT holds statutory and operational responsibility for adult mental health care across Suffolk, rather than MASH or the police.
Stated by Suffolk ConstabularyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A new MASH pathway is not viable because projected referrals would impose substantial operational impact and require structural redesign.
Stated by Suffolk ConstabularyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Adult mental health provision and clinical pathways are the responsibility of NHS commissioners and mental health providers.
Stated by Suffolk County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
SCC will not create a new MASH pathway for adult mental health-only referrals outside safeguarding or adult social care functions.
Stated by Suffolk County CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Avon
Concerns raised1
Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance
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
Continue discussions with PECS to commence pilots enabling Liaison and Diversion services to access and update the Digital Person Escort Record.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.
West Sussex, Brighton and Hove
Concerns raised1
Failure to ensure comprehensive cross-service information sharing and coordinated assessment and care
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
Launch the National Neighbourhood Health Implementation Programme to integrate health and social care teams and improve comprehensive community care.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Manchester South
Concerns raised1
Failure to communicate pacemaker extraction referral requirements between specialist and local cardiology services
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
Develop structured Emergency Department discharge communications and built-in referral reminders, while reviewing amendments to the current Emergency Department notes.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2025.
Action
Improve Emergency Department HIVE discharge workflows so staff can send discharge letters to relevant healthcare providers, including external cardiology departments.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Develop HIVE tip sheets and video guides on using the Emergency Department discharge navigator’s correspondence function and share them with relevant staff.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Build the HIVE discharge navigator so the correspondence workflow appears in the Emergency Department’s Dispo section.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Reinforce with Cardiology the importance of communicating with other secondary and tertiary care providers to maximise continuity of care.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Provide Cardiology Residents with focused training on copying inpatient discharge letters to relevant healthcare providers and referring patients to available pacemaker extraction services.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Wiltshire and Swindon
Concerns raised1
Systemic failure in communication between mental health and primary care
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
Use DocMan instead of email for DWF Hub referral-outcome communication with GPs, except when the referrer explicitly requests email.
Stated by Oxford Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Evaluate the DWF Hub’s DocMan process and use Trust governance processes to decide whether to adopt it across the other Hub teams.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Review AMHT communication practice, identify available changes and assess which options could strengthen controls against GPs missing important communications.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Discuss AMHT communication practices with teams to identify whether improvements are needed.
Stated by Oxford Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
DocMan is considered effective, timely and secure for communication between Oxfordshire Talking Therapies and GPs.
Stated by Oxford Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust will not change AMHT communication practices until it understands available options, utility and potential consequences.
Stated by Oxford Health NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cornwall and Isles of Scilly
Concerns raised1
Failure to ensure reliable sharing of ambulance clinical information between organisations
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.3
Action
Require CFT MIU teams to assess ambulance arrivals and obtain handover, history and records before accepting or booking patients into the unit.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Require LML staff to complete and hand over patient clinical records for every journey, including separate records for outbound and return transfers.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Require LML crews to provide records promptly alongside structured verbal handover, disseminate the policy to staff, and audit a sample of records monthly against national standards.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Adopting an electronic patient-record system was not financially viable for a medium-sized ambulance provider.
Stated by Cornwall Partnership NHS Foundation Trust and Lifespan Medical Limited and South Western Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Failure to provide frontline paramedics with vital mental health risk and capacity 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 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
Launch an investigation into ambulance responses to mental health crisis calls via NHS 111 and 999, covering triage, training, capacity assessment, and conveyance decisions.
Stated by Health Services Safety Investigations BodyStated plannedThe respondent said that this action was planned when they made their response on 13 August 2025.
Action
Review emergency mental health care pathways across Surrey, Sussex and Kent to establish a partnership framework for ambulance responses to suicidality.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Action
Work with partners to expand access to shared care records through the electronic Patient Care Record system.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The Healthcare Professionals Line is considered sufficient for safe, situation-specific multi-agency decisions instead of relying on previously prepared joint plans.
Stated by Surrey and Borders Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Providing mental health care for patients without physical health needs is outside the Trust’s commissioned remit.
Stated by Epsom and St Helier University Hospitals NHS TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Surrey and Borders Partnership provides local mental health services, while NHS Surrey Heartlands ICB commissions those services.
Stated by Epsom and St Helier University Hospitals NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Surrey Safeguarding Board will lead the Safeguarding Adults Review, with the organisation participating.
Stated by NHS Southwest London Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to maintain contemporaneous, accurate and immediately available documentation of external calls between community and hospital teams
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
Raise Alfie’s case with Neonatal Operational Delivery Networks and Regional maternity teams.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Direct control over how healthcare staff record clinical communications lies outside the organisation’s authority as a membership body.
Stated by Royal College of Paediatrics and Child HealthOutside remitThe respondent said that this matter was outside its role or authority.
Position
Trusts are responsible for ensuring effective recording and access processes where digital infrastructure is unavailable.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
