Recurring concern
Failure to communicate clinically important information reliably between care services
- Reports that mention this concern
- 144
- Times this concern has been raised
- 157
- Stated actions linked to this concern
- 271
What this concern includes
Includes failures of the cross-service clinical information communication process, including stale or unsupported guidance for emergency clinicians, omitted care decisions, inaccurate handovers and information not reaching involved services.
What is not included
- Excludes failures confined to a single clinician's knowledge or competence where no cross-service information communication issue is identified.
- Excludes generic training, staffing, documentation or information-system deficiencies that are not specifically tied to communicating clinically important information between care services.
- Excludes delays or failures in treatment, referral or emergency access where the material communication failure is not part of the concern.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 144 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Failure to record and share relevant information about contacts with other services and their outcomes
Inaccessibility of information about recent contacts with other services during emergency call-outs
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- London Borough of Camden
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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London Borough of Camden
Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
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London Borough of Camden
Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
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London Borough of Camden
Develop information-sharing arrangements with London Ambulance Service.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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London Borough of Camden
Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
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London Borough of Camden
Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
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Concerns raised1
Failure to share information between alcohol liaison and inclusion services
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Hampshire Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Hampshire Hospitals NHS Foundation Trust
Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.
-
Hampshire Hospitals NHS Foundation Trust
Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Hampshire Hospitals NHS Foundation Trust
Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.
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Concerns raised1
Failure to alert the forensic medical examiner to newly available mental health information
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to share relevant recent mental health information between mental health teams and general practitioners
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Develop GP access to mental health records.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Embed GP communication requirements in acute and community mental health team procedures, instruct managers, and monitor compliance after referral triage.
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Concerns raised1
Omission of blood test results from discharge summaries
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Epsom and St Helier University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Epsom and St Helier University Hospitals NHS Trust
Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.
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Concerns raised1
Failure to conduct nurse-to-nurse discharge communication between hospitals
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of North Midlands NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
University Hospitals of North Midlands NHS Trust
Require verbal nurse handover alongside written handover when transferring patients between hospitals.
-
Concerns raised1
Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Greater Manchester Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
NHS Greater Manchester Integrated Care Board
Review the case with the practice to identify further learning.
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NHS Greater Manchester Integrated Care Board
Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
-
Concerns raised1
Lack of structured and direct information sharing between hospital and ambulance services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- East Midlands Ambulance Service NHS Trust
- Health Services Safety Investigations Body
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
East Midlands Ambulance Service NHS Trust
Implement the SBAR communication framework for clinical handovers.
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East Midlands Ambulance Service NHS Trust
Develop and seek regional agreement for a maternity-specific SBAR handover model.
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East Midlands Ambulance Service NHS Trust
Implement the maternity-specific SBAR handover model across the EMAS footprint.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Health Services Safety Investigations Body
The HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.
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Department of Health and Social Care
Operational concerns are for the involved NHS trusts to address.
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Department of Health and Social Care
HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.
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Concerns raised1
Inadequate communication between inpatient and community services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to circulate important clinical risk information to treating clinicians
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Greater Manchester Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Greater Manchester Mental Health NHS Foundation Trust
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
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Greater Manchester Mental Health NHS Foundation Trust
Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.
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Greater Manchester Mental Health NHS Foundation Trust
Introduce the approved PARIS electronic clinical record system across Manchester services.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026