Recurring concern

Unreliable inter-agency information sharing for coordinated care

First to latest report 29 May 2013 — 15 Jun 2026

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

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

Reports and published responses 212 reports

See individual reports that have raised this concern, and the actions taken in response

1 Apr2016
Essex
Concerns raised1
1. Failure to communicate relevant dementia information to transport and support services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Roy Henry Oakley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Roy Henry Oakley was taken to Orsett Hospital for a routine blood test and, after being told to wait in the coffee shop without a settled collection arrangement, went to the ambulance bays and suffered an accident. He died on 12 June 2015. The report identified concerns that his dementia was not communicated to the transport and phlebotomy services, that no carer had been arranged to attend with him, and that information-sharing limitations may have played some part in his death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate relevant dementia information to transport and support services
Wider context from the report
“TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him. During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia. The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia. Other commissioned out services are in a similar position. The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley. ”
Source location
Mr Roy Henry Oakley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Feb2016
Liverpool and the Wirral
Concerns raised1
1. Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amy Rose COOPER · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
Wider context from the report
“It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care. This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information. This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place. Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome. ”
Source location
Amy Rose COOPER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Feb2016
Nottinghamshire
Concerns raised1
1. Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Philip Anthony Denning · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare
Wider context from the report
“5. As I understand it, the question of patients giving their consent for access to the records by CRI (and indeed for Nottinghamshire Healthcare to have access to CRI records) has not been considered by either organisation. Aside from potential cost and governance issues, none of the senior clinicians involved could tell me any disadvantage to such access being considered. It appears not to have been considered at all to date. There appears to be very little currently by way of joint working or information-sharing between CRI and Nottinghamshire Healthcare. ”
Source location
Philip Anthony Denning · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Dec2015
Inner South London
Concerns raised1
1. Lack of accessible universal records throughout the offender pathway
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

London Borough of Tower Hamlets
Ministry of Justice
Youth Justice Board for England and Wales
Stated actions 5
1. Ministry of Justice
  Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.
2. Ministry of Justice
  Roll out the Y2A Portal across England and Wales to improve information sharing between youth offending, probation and adult young offender services.
3. Youth Justice Board for England and Wales
  Implemented the Y2A Portal across England and Wales.
1. Youth Justice Board for England and Wales
  Considered how Youth Offending Teams could use the Y2A Portal to provide information to young adult establishments.
2. London Borough of Tower Hamlets
  Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.
Respondent positions 1
1. Ministry of Justice
  Practical and resource constraints prevent implementing a universal electronic records system between agencies.
  Unable to act
AI-generated summary

Imran DOUGLAS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of accessible universal records throughout the offender pathway
Wider context from the report
“The jury criticised the lack of access of HMP Belmarsh to the E Asset system and the fact that key documents from the Secure Training Centre were never accessed by the secure estate. The lack of a universal system of records throughout the offender’s pathway results in information on risk not being known to others and may contribute to future deaths. ”
Source location
Imran DOUGLAS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the Transitions Protocol and develop it into a Prison Service Instruction defining mandatory transition, safeguarding, assessment, information-sharing and collaborative-working procedures.

Verbatim wording from the response
“NOMS is currently reviewing the transitions protocol with a view to developing it into a Prison Service Instruction (PSI) which will define the national and local procedures which governors must implement to meet the specific needs of young people who will transition to adult custody, with a particular focus on supporting effective assessments and information sharing as well as promoting collaborative working between the”

Source location
2015-0446-Response-by-NOMS
Page 2 · response
Published 29 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Roll out the Y2A Portal across England and Wales to improve information sharing between youth offending, probation and adult young offender services.

Verbatim wording from the response
“Finally, it is accepted that a universal system of records conveyed by electronic communication between agencies would be desirable. However, there are practical and resource constraints that mean that it is not possible to implement such a system, and this is not the only way to make the improvements to information sharing that are necessary to mitigate risk and address your concern. As you will be aware from the inquest, the YJB has worked with NOMS to develop the ‘Y2A Portal’, which is a web-based system which aims to improve information sharing between Youth Offending Teams YOTs to probation services and adult YOIs. The Y2A portal has been successfully piloted with community services and is now being rolled-out across England and Wales.”

Source location
2015-0446-Response-by-NOMS
Page 2 · response
Published 29 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implemented the Y2A Portal across England and Wales.

Verbatim wording from the response
“We are clear that the safety and wellbeing of children and young people placed in custody is secured when there is timely and effective information sharing that allows for informed assessments of needs and the identification of risks to support appropriate interventions.”

Source location
2015-0446-Response-by-Youth-Justice-Board
Page 2 · response
Published 29 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Considered how Youth Offending Teams could use the Y2A Portal to provide information to young adult establishments.

Verbatim wording from the response
“As you have identified the use of different IT and case management systems by different organisations makes it difficult for these systems to speak to each other, impeding the flow of information. The Y2A Portal, about which we gave evidence to the inquest, has been successfully implemented across England and Wales. Additional work is underway to consider how the portal can be used by YOTs to provide information to young adult establishments if a young adult was previously known to them.”

Source location
2015-0446-Response-by-Youth-Justice-Board
Page 2 · response
Published 29 December 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update and recirculate guidance on transition planning, professional communication, information sharing, and detention placement plans by 31 March 2016.

Verbatim wording from the response
“16. This is now being updated in light of the issues raised during the course of the request and will be recirculated by 31 March 2016 to all YOS and CSC teams, to specifically address the following issues:”

Source location
2015-0446-Response-by-London-Borough-Tower-Hamlets
Page 5 · response
Published 29 December 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Practical and resource constraints prevent implementing a universal electronic records system between agencies.

Verbatim wording from the response
“Finally, it is accepted that a universal system of records conveyed by electronic communication between agencies would be desirable. However, there are practical and resource constraints that mean that it is not possible to implement such a system, and this is not the only way to make the improvements to information sharing that are necessary to mitigate risk and address your concern. As you will be aware from the inquest, the YJB has worked with NOMS to develop the ‘Y2A Portal’, which is a web-based system which aims to improve information sharing between Youth Offending Teams YOTs to probation services and adult YOIs. The Y2A portal has been successfully piloted with community services and is now being rolled-out across England and Wales.”

Source location
2015-0446-Response-by-NOMS
Page 2 · response
Published 29 December 2015
Open published response
23 Nov2015
Mid Kent and Medway
Concerns raised1
1. Failure to provide receiving care homes with relevant incident information
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alan Ludlow · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alan Ludlow died in hospital after suffering a subdural haematoma following a blow to his face from another resident at his care home, and subsequently developing pneumonia. The principal concern was that relevant information about the incident was not passed to the care home where the other resident was later placed, and that residential placements and changing needs must be appropriately assessed and reviewed.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide receiving care homes with relevant incident information
Wider context from the report
“The specific issue which came to my attention in this case was this: After the incident between Mr Ludlow and RT, RT was moved from the home to other accommodation. However, more recently, following deterioration in his mental state, he was admitted to another care home. This care home was not provided with any information about the incident which led to Mr Ludlow’s death by RT’s social worker or those who would be expected to know about the incident. The only reason the care home in fact became aware of the background was because it was part of the same group of care homes to which the original care home belonged and it was only by chance that someone recognised the name and made the connection. ”
Source location
Alan Ludlow · Prevention of Future Deaths report
Page 4 · concerns
Open source report
13 Nov2015
West Yorkshire (East)
Concerns raised1
1. Failure of relevant agencies to access and share information about vulnerable adults’ home environments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Irene Scholey · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Irene Scholey, an elderly and vulnerable 73-year-old woman, died from pneumonia and empyema after living permanently with two daughters in a household described as dysfunctional and inappropriate for her wellbeing. The report identified concerns that her wellbeing would have been safeguarded if relevant agencies had been able to access and share information about her home environment, and noted the potential benefit of extending the Multi Agency Safeguarding Hub to elderly and vulnerable adults.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of relevant agencies to access and share information about vulnerable adults’ home environments
Wider context from the report
“(3) The household was dysfunctional, was an inappropriate environment for Irene Scholey to be living in, and was a risk to her physical and emotional wellbeing. (4) A safeguarding alert was raised in respect of Mrs Scholey in April/May 2012. (5) Her wellbeing would have been safeguarded had all relevant agencies been able to access, and to share, information relating to the home environment in which Mrs Scholey was living. ”
Source location
Irene Scholey · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Oct2015
Leicester City and South Leicestershire
Concerns raised1
1. Failure to share clinically important information across mental health and primary care services
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Leicester City Council
Leicestershire Partnership NHS Trust
Stated actions 5
1. Leicester City Council
  Implement next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.
2. Leicester City Council
  Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.
3. Leicestershire Partnership NHS Trust
  Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.
1. Leicestershire Partnership NHS Trust
  Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.
2. Leicestershire Partnership NHS Trust
  Require medical and nursing staff to notify GPs when patients miss outpatient appointments.
AI-generated summary

Barry Thraves · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Barry Thraves, who had schizoaffective disorder and lived alone, took his own life after a relapse in May 2015; the time of death was unknown and his body was discovered on 29 May 2015. The report identified concerns about delayed psychiatric follow-up, lack of community mental-health support, inadequate risk consideration, and poor communication between services and Barry’s family and GP.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share clinically important information across mental health and primary care services
Wider context from the report
“4. Communication between the community mental health team and other stakeholders was poor, with important information that had been identified (that Barry was depressed and not compliant with his medication) not being shared with the GP, nor were the GP or psychiatric team aware that Barry was not receiving any community support. ”
Source location
Barry Thraves · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.

Verbatim wording from the response
“It is noted that the AMHP’s report to the Coroner identifies that the psychiatrists and AMHP assessing Mr Thraves were aware that he was not compliant with his medication. It is acknowledged that it should be standard practice for information to be shared with relevant professionals, such as the GP. In order to ensure this takes place in practice the Head of Service has e-mailed all AMHPs on 15 December 2015 to remind them of the importance of feeding back to GPs following an assessment under the Mental Health Act, where the GP was not part of that assessment.”

Source location
2015-0443-Response
Page 3 · response
Published 26 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.

Verbatim wording from the response
“Social workers across Adult Mental Health have been reminded of the importance of feeding back to the whole multi-disciplinary team and to carers, not solely the Registered Medical Officer.”

Source location
2015-0443-Response
Page 3 · response
Published 26 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.

Verbatim wording from the response
“Actions taken/planned:”

Source location
2015-0443-Response2
Page 3 · response
Published 26 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.

Verbatim wording from the response
“The LPT Discharge Policy is currently under review and the new policy is due to be approved in February 2016.”

Source location
2015-0443-Response2
Page 3 · response
Published 26 October 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require medical and nursing staff to notify GPs when patients miss outpatient appointments.

Verbatim wording from the response
“We agree with the inquest findings that communication between the Community Mental Health Team (CMHT) and wider stakeholders was poor. We agree that LPT did fail to communicate the fact that Barry did not attend his outpatient appointment to his GP and the steps regarding open contacts taken to prevent this happening in the future have been detailed are outlined above.”

Source location
2015-0443-Response2
Page 4 · response
Published 26 October 2015
Open published response
21 Oct2015
Gloucestershire
Concerns raised1
1. Lack of a process for sharing information and joining up care between community and obstetric providers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Samantha Beach · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Samantha Beach developed severe chest pain and intermittent tachycardia shortly after giving birth to her third child, but her symptoms were not appropriately investigated or escalated. She later suffered cardiac arrests and died after surgery for bleeding from a ruptured splenic artery aneurysm. Concerns included inadequate escalation of care, poor sharing of information between community and hospital services, and failure to involve the obstetric department when she attended the Emergency Department.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a process for sharing information and joining up care between community and obstetric providers
Wider context from the report
“(2) When Sam was being cared for in the community, there was no process to ensure the sharing of information or joining up of care between the midwives, out of hours, GP and obstetric department. ”
Source location
Samantha Beach · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jul2015
South London
Concerns raised1
1. Failure to share the GP’s mobile telephone number with the London Ambulance Service
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Anne Wilson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anne Wilson had a history of depression, had recently been discharged from psychiatric hospital, and was found deceased in her flat after failing to attend appointments and following concerns raised to the police. The principal concerns were the downgrading of the welfare-check request without informing her GP, inadequate training and guidance under the Metropolitan Police Service welfare-check policy, and failures in communication and joint working between the Metropolitan Police Service and London Ambulance Service.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share the GP’s mobile telephone number with the London Ambulance Service
Wider context from the report
“(5) The MPS did not share the G.P’s mobile telephone number with the LAS causing delay making further contact with the G.P. ”
Source location
Anne Wilson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Jun2015
Wiltshire and Swindon
Concerns raised2
1. Failure to communicate and acknowledge transfers of patient care between agencies
2. Failure to share mental health assessment information with other agencies involved in patient care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Approved Mental Health Professional/Social Work Service
Avon and Wiltshire Mental Health Partnership NHS Trust
Stated actions 4
1. Approved Mental Health Professional/Social Work Service
  Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.
2. Avon and Wiltshire Mental Health Partnership NHS Trust
  Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.
3. Avon and Wiltshire Mental Health Partnership NHS Trust
  Audit Wiltshire PCLS records for comprehensive triage, assessment and outcome communication documentation.
1. Approved Mental Health Professional/Social Work Service
  Review recording systems, establish a clear information-recording policy, store information on CareFirst, and share assessment reports with AWP and GPs.
Respondent positions 1
1. Avon and Wiltshire Mental Health Partnership NHS Trust
  Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.
  Existing arrangements considered sufficient
AI-generated summary

Elizabeth Godwin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Elizabeth Godwin died by suicide on 28 January 2013 after attaching a dog-lead ligature to a shower cubicle and hanging herself at home. The report raised concerns about how mental-health information was gathered, urgency assessed and monitored, information shared, responsibility allocated, and transfers of care communicated between agencies.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate and acknowledge transfers of patient care between agencies
Wider context from the report
“I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”
Source location
Elizabeth Godwin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to share mental health assessment information with other agencies involved in patient care
Wider context from the report
“I AM CONCERNED IN PARTICULAR AS TO THE FOLLOWING MATTERS: a) As to the way in which information is gathered from the family and others involved where there is a need for an individual to have a mental health assessment. b) As to how the urgency of carrying out that assessment, is assessed, recorded and monitored. c) As to how that information is shared with other agencies involved in the care of that patient. d) As to who has responsibility for the care of that patient including the carrying out of the mental health assessment and any treatment arising from it. e) As to how a transfer of that care between the agencies is communicated and acknowledged so that there is a clear audit trail. I would ask you to review the policy and procedures that you have in place to deal with the referral to another agency of a patient who appears to be suffering from mental health issues having regard to the above concerns. ”
Source location
Elizabeth Godwin · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.

Verbatim wording from the response
“Any other transfer of care should be documented in the same way as a clear statement of who is doing what - across the different teams in Wiltshire Council and AWP and across daytime hours and out of hours – which has been agreed by both organisations and needs to be clearly communicated to the families and the GP and anyone else who needs to be informed. This should be clearly recorded on the health data base RiO and the social care system CareFirst and via any other correspondence that is required.”

Source location
2015-0233-Response-by-Wiltshire-Council
Page 5 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Communicate triage, assessment and referral outcomes to referrers, service users, families, carers and relevant agencies.

Verbatim wording from the response
“The Trust CPA and Risk Policy outlines the requirement that referrals not requiring assessment will be returned to the referrer with referral outcome decision and recommendations for further intervention.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit Wiltshire PCLS records for comprehensive triage, assessment and outcome communication documentation.

Verbatim wording from the response
“The Trust services in Wiltshire have recently audited the records of the PCLS service recently and have found these to be comprehensive.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 2 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review recording systems, establish a clear information-recording policy, store information on CareFirst, and share assessment reports with AWP and GPs.

Verbatim wording from the response
“Systems have been reviewed and there is a clear policy on how information is recorded. All information is now stored on the council’s customer information system, CareFirst, which can be accessed 24 hours a day. If the AMHP undertakes a Mental Health Act assessment a copy of that report is sent to AWP to be uploaded on RiO and is also sent to the GP.”

Source location
2015-0233-Response-by-Wiltshire-Council
Page 3 · response
Published 19 June 2015
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing policies and processes for family involvement, triage, communication, recording and monitoring address the identified assessment and care concerns.

Verbatim wording from the response
“The Trust Care Programme Approach, (CPA), and Risk Policy outlines that staff will involve families and carers in the full CPA process including assessment of risk. The Trust has in place further guidance on undertaking clinical risk assessment which also outlines that effective engagement and communication with and between the service user, their carer(s), other professionals and agencies, underpins all risk assessment and management.”

Source location
2015-0233-Response-by-Avon-and-Wiltshire-NHS-Trust
Page 1 · response
Published 19 June 2015
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to communicate relevant dementia information to transport and support services

Concerns raised1

Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services

Concerns raised1

Failure to establish consent arrangements and information-sharing between CRI and Nottinghamshire Healthcare

Concerns raised1

Lack of accessible universal records throughout the offender pathway

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide receiving care homes with relevant incident information

Concerns raised1

Failure of relevant agencies to access and share information about vulnerable adults’ home environments

Concerns raised1

Failure to share clinically important information across mental health and primary care services

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Lack of a process for sharing information and joining up care between community and obstetric providers

Concerns raised1

Failure to share the GP’s mobile telephone number with the London Ambulance Service

Concerns raised2

Failure to communicate and acknowledge transfers of patient care between agencies

Failure to share mental health assessment information with other agencies involved in patient care

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Stated actions 5

Respondent positions 1

Stated actions 5

Stated actions 4

Respondent positions 1