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.
West Sussex, Brighton and Hove
Concerns raised1
Failure of probation oversight to ensure awareness and proper administration of mental health treatment requirements
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Collaborate with the Forensic and Specialist Directorate to examine Kent Secondary Care Mental Health Treatment Requirement practice and responsibilities across the intervention.
Stated by Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 8 August 2024.
East London
Concerns raised1
Lack of checks on sharing up-to-date and accurate risk assessments
This report raised 24 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
Develop and use a process map guiding Police Offender Managers and supervisors to obtain, record and manage risk information before and after prison releases.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 2 August 2024.
Action
Maintain mandatory professional registration for Probation Officers to strengthen continuing development, performance and accountability.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 2 August 2024.
East London
Concerns raised1
Failure of communication between care providers and public services to identify deterioration in living conditions and health
This report raised 5 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.9
Action
Develop an escalation procedure for partners to flag high unmitigated risk or differing risk assessments, including reviews of no-reply and refusal-of-care protocols.
Stated by London Borough of NewhamStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Deliver reflective sessions for Adult Social Care staff and selected partner staff on safeguarding decision-making, multi-agency working and Making Safeguarding Personal.
Stated by London Borough of NewhamStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Deliver reflective sessions for Adult Social Care staff and selected partner staff on risk assessment and management, information sharing, coordinated intervention, thresholds and social isolation.
Stated by London Borough of NewhamStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Update safeguarding, notification, response and monitoring policies, including 24-hour reporting, 48-hour response expectations and proactive follow-up.
Stated by Sunlight CareStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Action
Implement new inter-agency communication and escalation strategies for timely safeguarding escalation across teams.
Stated by Sunlight CareStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Introduce regular multidisciplinary reviews for cases involving self-neglect, incorporating physical, mental and social wellbeing in decision-making.
Stated by Sunlight CareStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Action
Meet with Newham safeguarding teams to review current pathways and organisational interfaces for improving communication about high-risk service users.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Review the process for responding to high-risk service-user concerns with Trust staff, reinforcing responsibilities to arrange multi-agency professionals’ meetings.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Implement a dressing-clinic standard operating procedure providing 30-minute service-user appointment slots instead of 10-minute slots.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust cannot comment on behalf of the local authority or domiciliary care company regarding their communication and care arrangements.
Stated by East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Failure to share medical notes and information between private practitioners and NHS providers
This report raised 5 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.5
Action
Review and develop a consent process for recording and sharing information when patients receive both NHS and private care.
Stated by South West London and St George'S Mental Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Action
Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.
Stated by South West London and St George'S Mental Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Continue trialling Summary Care Record access with private hospitals and privately funded healthcare services.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Action
Work with an Expert Advisory Committee to seek approval for independent-sector rollout and consider its scope, exclusions, constraints, and caveats.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Action
Review the interface between NHS and non-NHS-funded independent health providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
National systems and guidance for information sharing between NHS and private providers are principally matters for NHS England and the Department of Health.
Stated by South West London and St George'S Mental Health NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Clinical information cannot ordinarily be shared between NHS and private practitioners without explicit patient consent, except where risk makes sharing essential.
Stated by South West London and St George'S Mental Health NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NHS England is responsible for improving information sharing and reviewing the interface between NHS and non-NHS-funded independent providers.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for delivering shared care records sits with local Integrated Care Boards.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised2
Failure to share information regarding deterioration in mental health with the appropriate team
Failure to inform the GP of declined attendance for medication
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.3
Action
Email Adult Mental Health Teams when online records are unavailable, follow up until a decision is received, and escalate unsuccessful contact to team leaders.
Stated by Oxfordshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Share qualifying mental-health reports with GPs, explain the reasons, and request follow-up and identification of social-care needs.
Stated by Oxfordshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Escalate urgent concerns by contacting GPs immediately or referring cases to the Professional Support Team for evaluation and decision.
Stated by Oxfordshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Manchester South
Concerns raised1
Failure to share information effectively between agencies supporting victims of domestic abuse
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure to communicate identified fractures in discharge information
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
Reviewed the emergency department's process for subsequent image review to assess its robustness and alignment with national practice.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.
Action
Launch a comprehensive electronic health record to reduce risks arising from clinicians using multiple systems.
Stated by the Princess Alexandra Hospital NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing process of subsequent emergency-department consultant image review was considered as robust as possible and consistent with national practice.
Stated by the Princess Alexandra Hospital NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
County Durham and Darlington
Concerns raised1
Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately
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.4
Action
Test and roll out CDDFT electronic patient-record access on TEWV clinicians’ laptops for joined-up assessments and information sharing.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Continue team discussions and daily MDT reminders about documenting and verbally handing over homelessness and other risk information.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Audit and deep-dive liaison documentation to verify that verbal handovers to other Trusts and services are recorded, addressing issues through supervision and team meetings.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Action
Reissue an open letter to all staff supporting appropriate information sharing while balancing patient confidentiality and safety.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Birmingham and Solihull
Concerns raised1
Lack of formal notification of police disagreement about risk category
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.3
Action
Share information with health systems on establishing multi-agency governance, delivery structures, risk management, escalation and communication.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Action
Issue guidance to health systems covering multi-agency governance, delivery structures and real-time and retrospective escalation processes.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 June 2024.
Action
Review and update the WMP Missing Person Policy to address daily appraisal attendance, clinician risk assessments, recording, and investigation-closure notifications.
Stated by West Midlands PoliceStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Operational and clinical partners are best placed to respond to relevant concerns and reassess local risk, communication and escalation processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The mental health trust cannot formally record differing risk opinions because it lacks access to police systems.
Stated by West Midlands PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Specific issues concerning police ways of working are for the National Police Chiefs’ Council, College of Policing and West Midlands Police to address.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Each Chief Constable decides whether and when to implement Right Care Right Person and which elements of the national framework to adopt.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The APCC cannot mandate its members to undertake actions in response to the identified safety concerns.
Stated by Association of Police and Crime CommissionersOutside remitThe respondent said that this matter was outside its role or authority.
Position
Operational implementation of Right Care, Right Person is assigned to Chief Constables rather than Police and Crime Commissioners.
Stated by Association of Police and Crime CommissionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
RCRP did not apply because the case was treated as a missing person involving immediate risk requiring police response.
Stated by National Police Chiefs’ CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure of electronic patient records to automatically share renal team entries between hospitals
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.2
Action
Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Provide cross-record patient links between the two electronic patient records and links to the GP Summary Care Record through the Master Patient Index.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Care Quality Commission will assess the incident and determine whether further regulatory action is needed.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
