Recurring concern
Unreliable inter-agency information sharing for coordinated care
- Reports that mention this concern
- 212
- Times this concern has been raised
- 235
- Stated actions linked to this concern
- 492
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 212 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure of health care departments to communicate crucial patient information
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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NHS England
Develop a shared care record for Derby and Derbyshire to address information-sharing problems across multiple healthcare providers.
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NHS England
Use interim shared-care communication systems, including Mental Health Liaison Team information-sharing and a mental health risk triage assessment form.
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NHS England
Task the Learning from Deaths Forum with considering system improvements alongside the move to a shared care record.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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NHS England
Coordination and management of discharge care plans fall outside NHS Digital’s area of responsibility.
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NHS England
A system is unlikely to replace professional curiosity and clinical judgement, which are supported by existing medical and nursing training.
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Concerns raised1
Poor information sharing and joint risk recognition across statutory agencies
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Greater Manchester Police
- NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Greater Manchester Police
Conduct district safeguarding-team deep-dive reviews and circulate domestic abuse, child-protection and adults-at-risk triage expectations.
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Greater Manchester Police
Establish a specific safeguarding-team triage training course incorporating information-sharing guidance.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS Greater Manchester Integrated Care Board
Other named respondents are responsible for addressing the coroner’s concerns; this response covers only broader learning-sharing issues within its remit.
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Concerns raised1
Lack of a joint police-health policy for sharing information about vulnerable missing persons with mental health difficulties
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised4
Failure to obtain consent for disclosure of safeguarding information to other agencies
Unclear central point of contact for investigative agencies and care homes
Lack of a system for sharing safeguarding information with care homes
Information-sharing arrangements failing when a person is not admitted from a registered facility
Linked response
- The Limes Residents Association Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
The Limes Residents Association Limited
Contact receiving care homes immediately when residents consider residential care and share all available information by telephone and follow-up letter.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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The Limes Residents Association Limited
GP confidentiality means the suitability information received about prospective residents is very limited.
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Concerns raised1
Failure to reliably and consistently share medical records and information between Trusts
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Pennine Care NHS Foundation Trust
- Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Tameside and Glossop Integrated Care NHS Foundation Trust
Operate joint mental health inpatient transfer and return-transfer pathways covering physical deterioration, chronic conditions and required clinical information.
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Pennine Care NHS Foundation Trust
Implement the joint Standard Operating Procedure for shared physical and mental healthcare of older inpatients requiring medical input.
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Pennine Care NHS Foundation Trust
Create and apply structured pathways for acute deterioration, chronic-condition advice, information gathering, and transfers of care.
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Pennine Care NHS Foundation Trust
Deliver and document self-directed training for staff covered by the approved joint SOP.
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Concerns raised1
Failure to route safeguarding alerts to the appropriate generic mental health service mailbox
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to share safeguarding referral information and reasons with relevant third parties, services or agencies
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to share anticoagulant reversal risks with non-tertiary centres
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of digital information access between acute and community trusts
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Department of Health and Social Care
The local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
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NHS Greater Manchester Integrated Care Board
Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.
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Concerns raised1
Failure to share relevant physical healthcare check results between primary and secondary healthcare providers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026