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.

Reports and published responses 212 reports

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

  1. West Yorkshire (East)

    AI-generated summary

    Anne Whitworth · 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 Whitworth developed worsening abdominal symptoms and became acutely unwell on 8 September 2013. She suffered respiratory and cardiac arrest while being taken to hospital and died later that evening; a post-mortem examination identified aspiration of gastric contents due to intestinal obstruction caused by volvulus of the sigmoid colon. Concerns included the failure to access her prior GP records out of hours and a missed opportunity to escalate her treatment.

    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 ensure emergency doctors are aware of relevant GP consultations, symptoms and referrals

    Wider context from the report

    “1. The Emergency Doctor stated that had he been aware of the GP consultation on 30th August 2013 and her then symptoms and the fact that a referral to a gastroenterologist had been made, his management of Mrs Whitworth would have been different. ”

    Source location

    Anne Whitworth · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Graham Darby · 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

    Graham Darby, who had alcohol dependence, was found dead at his home the day after being evicted and forcibly re-entering the property; the inquest concluded that the cause of death was suspension by ligature and that his death was a suicide. A significant concern was that a reported threat to take his own life using a knife and rope if evicted was not passed on to the housing agency, and was therefore not sufficiently flagged 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 clearly flag direct suicide threats to agencies responsible for housing and eviction

    Wider context from the report

    “That there were a number of agencies involved in both trying to assist Mr Darby and to deal with his anti-social behaviour (which led to the eviction). That although information was passed on generally between agencies and that communication was ongoing about Mr Darby, the evidence disclosed that one significant piece of information was not flagged up as it was not made sufficiently clear to Family Mosaic who were responsible for his housing and eviction. This was that the psychiatrist from ARC made a specific observation that Mr Darby had said that he had a knife and a rope in his property and would take his own life if evicted. The witness from Family Mosaic said that this particular piece of information was not passed on and that if it had been different actions may have been taken. Such direct threats should be flagged up in similar circumstances. ”

    Source location

    Graham Darby · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Liverpool

    AI-generated summary

    Wilfred Roy Aspinwall · 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

    Wilfred Roy Aspinwall was a frail prisoner with several co-morbidities who sustained falls, including a hip fracture, and later died after a gradual deterioration in health on 21 April 2013. The inquest concluded that he died from natural causes. A substantive concern was that the PPO report and Clinical Review had not been shared with the healthcare provider at HMP Liverpool.

    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 PPO reports and Clinical Reviews with prison healthcare providers

    Wider context from the report

    “At the inquest hearing it was clear that the PPO report and Clinical Review had not been sent to nor shared with the Healthcare provider at HMP Liverpool. It might be considered good practice for future reports, in all prison fatalities should to be sent to either the head of healthcare and/or the commissioning NHS Trust to ensure that recommendations have an optimal effect. ”

    Source location

    Wilfred Roy Aspinwall · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    Miss Abiola Dosunmu · 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

    Abiola Dosunmu developed abnormal blood tests, proteinuria and symptoms that were treated as cellulitis, before rapidly deteriorating and being found dead at home on 24 August 2012. The report identified concerns about failures to communicate the proteinuria and abnormal results, inadequate follow-up and monitoring, and a missed opportunity to diagnose and treat SLE earlier.

    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 discharge information and monitoring needs to primary care

    Wider context from the report

    “(3) The Trust failed to send the GP a discharge summary or communicate to the surgery the significance of the raised ESR and CK and the need for further monitoring. ”

    Source location

    Miss Abiola Dosunmu · 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

    Produce discharge notifications for patients who self-discharge.

    Verbatim wording from the response

    “a) Failure to send a discharge summary: A discharge summary should have been completed when Abiola self-discharged. As a result of this case, the Trust conducted an audit which showed that it is not consistent practice to issue discharge summaries for self-discharging patients. This issue was”

    Source location

    2014-0209-Response-by-Kings-College-Hospital
    Page 1 · response
    Published 5 May 2014

    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

    The Trust states that the GP was informed by telephone and received a discharge summary containing the abnormal results.

    Verbatim wording from the response

    “b) Failure to communicate the significance of the raised ESR and CK and need for further monitoring to Abiola’s GP: The Trust contacted the GP by telephone informing the GP that Abiola had self-discharged, recommending oral antibiotics and stressing the importance of IV antibiotics and need for her to attend ED if her condition deteriorated. The Trust also notes that ED generated, and the GP received, a 4 page discharge summary which included (because it was generated on 9 March 2013) the abnormal results identified during Abiola’s admission.”

    Source location

    2014-0209-Response-by-Kings-College-Hospital
    Page 2 · response
    Published 5 May 2014

    Open published response

  5. Inner South London

    AI-generated summary

    Gary Richards · 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

    Gary Richards had a forensic history and was at increased risk of taking his own life. He deliberately jumped in front of a moving train at Ladywell Station on 10 October 2012 and died at KCH on 16 October 2012. Concerns included inadequate assessment and communication of his self-harm risk, failures in follow-up and reliable communication, and uncompleted actions addressing identified service-delivery problems.

    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 patient risk and vulnerability to relevant agencies

    Wider context from the report

    “(1) Psychiatric staff did not properly assess his risk of self harm, nor communicate his vulnerability to others. At discharge on 10/05 his risk of self harm was not fully measured. On being seen on 14/06 his risk assessment was not recorded and the risk plan not sent to the GP. The consultant explained that the risk was not mitigatable as no mental illness was found. Evidence was heard that his forensic history indicated that he belonged to a group of patients with 80 times the risk of suicide compared with the general population, yet he was considered at low risk. The value of performing a proper risk assessment to demonstrate the risks and vulnerabilities of the patient to other agencies, such as housing and social services, does not seem to have been considered, although it was reluctantly conceded by the consultant to be of value especially as homelessness presented as the primary problem. ”

    Source location

    Gary Richards · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Leicester City and South Leicestershire

    AI-generated summary

    Michael Anthony Tarratt · 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

    Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing 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

    Failure to exchange prescription information between treatment services and the GP

    Wider context from the report

    “(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. ”

    Source location

    Michael Anthony Tarratt · 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

    Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.

    Verbatim wording from the response

    “The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    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

    Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    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

    Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    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 case notes for GP correspondence within 14 days and repeat the audit every six months.

    Verbatim wording from the response

    “A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response

  7. South London

    AI-generated summary

    Simon William McAndrew · 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

    Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

    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 ensure key clinical staff can access important electronic information held in different NHS trusts

    Wider context from the report

    “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital. Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM. For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust. This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves. ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 3 · 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 and recognise information about psychiatric responsibility between NHS trusts

    Wider context from the report

    “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital. Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM. For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust. This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves. ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Berkshire

    AI-generated summary

    Mrs Nutbeam · 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

    Mrs Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

    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 procedure for transferring patient information between different Trusts

    Wider context from the report

    “(1) Staff at St. Peter’s Hospital did not contact Wexham Park Hospital to advise of the recent admission, treatment and symptoms even though they were once aware that Mrs Nutbeam had a follow up appointment at Wexham Park Hospital some two days later because they arranged that appointment. Concern is the apparent lack of any procedure to allow information to be transferred between different Trusts in different Counties. There was no letter given to Mrs Nutbeam to accompany her to the subsequent appointment. ”

    Source location

    Mrs Nutbeam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Shropshire, Telford and Wrekin

    AI-generated summary

    Christine Ann WILLIAMSON · 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

    Christine Ann Williamson, aged 62, died following a physical assault by her husband, who had advanced Alzheimer’s dementia and was unaware of his actions or their consequences. The concerns included the absence of an earlier referral and assessment of her as a vulnerable adult at risk, and inadequate information sharing that might have enabled preventative measures.

    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 significant safeguarding information between concerned professionals

    Wider context from the report

    “(2) Had such an earlier assessment as a Vulnerable Adult been made then discussions would have taken place with all concerned with every having significant information sharing it with others. This would have increased the likelihood that preventative measures would have been put in place as the deceased being better or fully informed as to the increased risk she was putting herself in by continuing to live with her husband whose condition was deteriorating. The best illustration of this lack of shared information is that the evidence given at the Inquest when all relevant witnesses were present, should have taken place in a meeting before the situation became critical. ”

    Source location

    Christine Ann WILLIAMSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Gateshead and South Tyneside

    AI-generated summary

    Joan Farran · 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

    Joan Farran, who had multiple co-morbidities and was cared for by her adult son, died at home from bronchopneumonia due to chronic obstructive pulmonary disease and Alzheimer’s disease. The report states that her death from a potentially treatable pneumonia was contributed to by neglect in obtaining medical support and treatment. Concerns included inadequate coordination and information-sharing between agencies, limited assessment of the home environment, withdrawal of community visits without replacement services, and the cancellation of a GP home visit without further follow-up.

    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 coordinate and share information across community care agencies

    Wider context from the report

    “7. All of these visits appear to have been conducted in the deceased' bedroom and no visits were made to any other part of the house and particularly the living room, dining room, kitchen and back yard. Significantly it is these areas which were found to be excessively cluttered during the investigation by the Police, subsequent to the deceased' death. 8. The Inquest received evidence from an Environmental Health Office who gave evidence that the clutter within the home was at least 8 months old but acknowledged that because this was a criminal investigation, he did not asitwere dig too deep into the material present to identify exact dates as to the packaging and other detritus which was present. 9. The Community Matron was himself unwell in the period March to July 2012 and subsequently from July ceased further visits. No other external services appear to have visited this home between July and December 2012 to determine how the deceased was progressing. 10. There were concerns expressed by the General Practice and in particular by the Pharmacy who were dispensing the deceased' repeat prescriptions that there were instances of non-collection of the medication and indeed a review was carried out late in that year as to the nature of the medication the deceased needed. There was no further visit at that stage to the deceased' home however. 11. Having received a communication from the deceased' son, on the 7th December as to his mother's state of health the Community Matron did make direct contact with the practice in order to try and ensure an appointment was made. He was nonetheless of a view that at that juncture there should in fact be some urgent and immediate visit but the matter was left on the basis only of a home visit to be made on the Monday 10th December. 12. That visit was cancelled and no further contact was made with the deceased or visit made to the home by the practice or any other outside agency. 13. Any visit that was made at that juncture or indeed at any earlier juncture which sought to visit more extensively within the home would have had clearly demonstrated that all was not well in the care and management of the deceased by the son and indeed that the son himself as a carer, was incapable of meeting the needs of his mother and himself was suffering from chronic problems, in all probability alcoholism. 14. The opinion of the NeuroPathologist who examined the deceased' body was of the opinion that the deceased was suffering from established dementia and that that should have been apparent to those who had her care. It was undiagnosed. If the deceased had received even the basic of treatment during the week immediately before her death, there is every reason to believe the deceased' death from a treatable condition would have been avoided. 15. My concern on this occasion is that although there were at least three agencies actively engaged in the care of this lady , or called to review her care during the months preceding her death, there has been a failure to co-ordinate information available to them. 16. There is evidence that they have failed to appreciate or investigate more robustly and objectively circumstances of the deceased' situation ,to be easily put off by the deceased' own presentation in the case of the visit by Social Services early in 2012, reassured that others had apparently raised no issue and in the event were continuing to visit , when ultimately they chose to withdraw those services very soon after. 17. The complaint the daughter should have at least led to an opportunity to examine the living accommodation more fully and more pointedly to maintain some contact into the future months and not to rely on the result and conclusion of one single visit and in any event to maintain a co-ordinated overview between the Community Matron Services, the GP and Social Services. 18. This incident occurring as it has at or about the same time as Elizabeth and Robert Douthwaite ( 17th January 2013) highlights the need for a robust and co-ordinate approach between the several agencies working within the Community who may come into contact with individually vulnerable individuals within the community. The active sharing of information and staged reviews are an essential element leading to co-ordinated care strategies. ”

    Source location

    Joan Farran · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

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

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Data last updated 7 September 2026