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.
Hampshire, Portsmouth and Southampton
Concerns raised1
Lack of timely cross-local access to relevant electronic patient records
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.1
Action
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
North West Wales
Concerns raised1
Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations
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
Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
Action
Develop a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
Action
Work with the Chief Information Officer to consider options for a more timely MHLD digital-record solution.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implementation of the planned MHLD digital records system cannot proceed as expected because national arrangements changed following a Welsh Government decision.
Stated by Betsi Cadwaladr University LHBUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised2
Failure to pass pertinent information to the ambulance service
Failure to pass pertinent clinical information to the GP
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.2
Action
Hold a daily flash meeting to discuss activities, concerns, changes in behaviour, illness and professional contacts.
Stated by Leonard Cheshire DisabilityStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Maintain a robust handover process for communicating concerns about supported people.
Stated by Leonard Cheshire DisabilityStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Manchester South
Concerns raised1
Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes
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.2
Action
Explore extending referral-platform benefits to other Greater Manchester services.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Discuss with information officers and the Digital Delivery Executive how to develop the referral-platform proposal into a funded project.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Birmingham and Solihull
Concerns raised2
Delays in primary care organisations providing important patient updates to GPs
Failure of digital systems used by different health organisations to communicate
This report raised 7 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
Use the Shared Care Platform to enable participating organisations to access clinical information and improve information exchange.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 July 2023.
Action
Improve digital capability so relevant information is automatically added to GP patient records.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Action
Develop interoperable shared care records to enable safe and secure information sharing across NHS and social care services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Accredited interoperable GP systems and widespread digital capability should address the sharing of important clinical information.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Failure of systems to make involved agencies aware of safeguarding referrals and concerns
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.
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
Implement the One Team community mental health model with multi-agency working, clear safety plans, named workers, feedback, and wider community support.
Stated by Berkshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 June 2023.
Action
Make the Integrated Multi-Disciplinary Team operational to discuss complex cases, share information, formulate risk, and determine suitable pathways and care plans.
Stated by Berkshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 June 2023.
Blackpool and the Fylde
Concerns raised2
Difficulty sharing information between service providers using different databases
Inconsistent availability of access to mental health records across service providers
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to share risk information and coordinate risk management planning between specialist and stepdown services at discharge
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.6
Action
Update and ratify the CADAT discharge policy to require liaison, joint risk planning, and communication with skin clinics about aesthetic treatment.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 June 2023.
Action
Develop a joint working protocol between CADAT and NELFT step-down services covering risk information sharing, joint risk management and discharge planning.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Share the joint working protocol with staff and discuss it in team business meetings.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Deliver a learning event on completing and updating risk assessments, including relevant assessment parameters.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Undertake a quality improvement project to identify and address structural, process and cultural gaps in risk assessment and risk management.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 June 2023.
Action
Develop risk formulation to support robust risk assessment and risk management processes and improve patient safety.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
SLAM and NELFT are responsible for addressing liaison, communication, information sharing and staff training concerning Conrad’s care.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Swansea and Neath Port Talbot
Concerns raised1
Lack of integrated electronic access to medical and treatment records between treating teams
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
Enable two-way WCCIS information sharing between Swansea community mental health and drug and alcohol teams.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Further WCCIS rollout is on hold pending Welsh Government approval of National Programme Team recommendations.
Stated by Swansea Bay University Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Local Authority must request and implement any amendments to WCCIS system functionality.
Stated by Swansea Bay University Local Health BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Hampshire, Portsmouth and Southampton
Concerns raised1
Incomplete information sharing between healthcare and prison security 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Operational staff cannot access healthcare records because medical confidentiality prevents direct access to SystmOne.
Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing multidisciplinary meetings, briefing sheets and observation books are considered sufficient to share necessary prisoner safety information.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
