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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to achieve clear communication of key 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.
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
Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.
Stated by Pembroke Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Position
Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Stated by NHS Devon Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Failure of primary and secondary care providers to access each other’s electronic medical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
Stated by Esher Green SurgeryStated completedThe respondent said that this action was complete when they made their response on 16 January 2025.
Action
Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
Stated by Esher Green SurgeryStated plannedThe respondent said that this action was planned when they made their response on 16 January 2025.
Action
Provide live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.
Stated by Surrey Heartlands ICBStated completedThe respondent said that this action was complete when they made their response on 16 January 2025.
Action
Implement a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.
Stated by Surrey Heartlands ICBStated plannedThe respondent said that this action was planned when they made their response on 16 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Electronic record connectivity is a commissioning responsibility for the Surrey-wide ICB, not an individual GP practice.
Stated by Esher Green SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The practice cannot independently improve communication across Surrey; practice-level action will not address the wider issue without a uniform SABP approach.
Stated by Esher Green SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Surrey Care Record access is considered sufficient to resolve the risk of GPimhs staff lacking necessary GP record information.
Stated by Surrey Heartlands ICBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex, Brighton and Hove
Concerns raised1
Lack of sufficient recording, flow and sharing of information across agencies and teams
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.7
Action
Implement direct handover of police-conveyed patients to Trust staff.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Revise and implement the Trust-wide Missing Persons policy, including risk assessment, detention, communication, escalation and post-departure procedures.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Disseminate Missing Persons policy guidance, flow charts and documentation to wards, emergency departments and clinical staff.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Review and update emergency-department triage, mental-health liaison, observation and communication documentation with partner clinicians.
Stated by UHSxStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Action
Send daily reports of police-referred missing patients to Trust and emergency-department nursing leaders for risk review, feedback and learning.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Hold fortnightly multidisciplinary missing-patient meetings involving nursing, emergency, police, mental-health and security teams.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Develop and recirculate quick-reference absconding guidance, flow charts and missing-person documentation for wards and emergency departments.
Stated by UHSxStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
West Yorkshire (Western)
Concerns raised1
Failure to maintain communication between the college and external mental health support organisations
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
Discuss multi-agency safeguarding communication with the NHS South West Yorkshire Partnership Foundation Trust.
Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Review and amend procedures for contacting external safeguarding agencies, including obtaining updates under Welfare Plans and during permanent exclusion.
Stated by The Duchess of Somerset’s HospitalStated completedThe respondent said that this action was complete when they made their response on 5 November 2024.
Action
Remind external agencies of their safeguarding information-sharing responsibilities under applicable national guidance.
Stated by The Duchess of Somerset’s HospitalStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Implementing multi-agency communication changes is outside the College’s authority and requires discussion at a higher level.
Stated by The Duchess of Somerset’s HospitalOutside remitThe respondent said that this matter was outside its role or authority.
Position
The NHS Trust responsible for CAMHS services is responsible for setting out steps to improve local information-sharing.
Stated by The Duchess of Somerset’s HospitalRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Failure to share information supplied to 111 online with ambulance call handlers
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England will respond to concerns about sharing and accessing information from NHS 111 and patient records.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS 111 online does not transfer information when advising users to call 999 because further telephone assessment is deliberately required before ambulance dispatch.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised1
Failure to communicate clinically relevant information between services about epilepsy and psychosis
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
Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 8 October 2024.
Manchester South
Concerns raised1
Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
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.2
Action
Integrate mental health practitioners within NWAS and GMP control centres through the Mental Health Tactical Advice Service.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Action
Provide a mental health option on NHS 111 enabling callers to access Trust mental health practitioners.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.
Stated by Trafford Borough CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Policing, advocacy, communication, and interagency information access should be addressed by the other individuals and organisations named in the report.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Communication arrangements between mental-health agencies should be established locally by Greater Manchester and other local bodies.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Establishing communication arrangements and a central repository for information across mental-health agencies sits outside CQC’s remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Department of Health and Social Care is better placed to address communication arrangements across mental-health agencies.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised2
Failure to share all relevant information with mental health practitioners in a timely manner
Lack of defined information-sharing arrangements for the Rapid Response Service
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
Operate the newly implemented Rapid Response Service through a single point of contact to support consistent guidance and information sharing with police.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2024.
Action
Continue monitoring information sharing between the Trust and Sussex Police through the Rapid Response Service.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2024.
Action
Develop a trust-wide Standard Operational Procedure covering partner contact arrangements, risk management, documentation, information sources and evidence-based decisions.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The operational Blue Light Line and existing policy are sufficient; police officers will not need to change practice when Rapid Response launches.
Stated by Sussex PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
County Durham and Darlington
Concerns raised1
Failure to alert the drug treatment provider to dispensing outside the prescription
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex, Brighton and Hove
Concerns raised1
Failure of LDS and police information sharing about custody mental health presentation
This report raised 11 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
Develop a standard template and guidance with NPCC and CPS for transferring relevant Liaison and Diversion assessment information to police.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Maintain documented, verbally delivered and CCTV-recorded custody handovers, with live risk updates, shared access, audit trails, staff training and peer review.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Record custody risks and concerns discussed with Liaison and Diversion staff on the detainee’s risk assessment and care plan.
Stated by Sussex PoliceStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Consider best practice through the Betterment Workstream, including a nationally recognised pre-arrival risk assessment for communicating custody risks.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
Action
Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Add a standard template for written information shared with police colleagues to the Custody Pathway SOP.
Stated by Midlands Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
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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.
