First reported 27 Sep 2013•Latest report 10 Jun 2026
Definition
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.
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.
Reports
144
Distinct published reports
Individual concerns
157
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
271
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 Care25
NHS England24
Essex Partnership University NHS Foundation Trust5
Greater Manchester Mental Health NHS Foundation Trust5
NHS Greater Manchester Integrated Care Board5
Pennine Care NHS Foundation Trust5
Care Quality Commission4
Manchester University NHS Foundation Trust4
Aneurin Bevan University LHB3
Birmingham and Solihull Mental Health NHS Foundation Trust3
Cheshire and Wirral Partnership NHS Foundation Trust3
Health Services Safety Investigations Body3
Mid and South Essex NHS Foundation Trust3
Midlands Partnership University NHS Foundation Trust3
North West Ambulance Service NHS Trust3
NHS trust94
Executive non-departmental public body28
Ministerial department27
Healthcare site25
Integrated care board16
Police force10
Local health board8
Private limited company6
Type not available5
English county council4
Health and social care service regulator4
Executive agency3
Prison or young offender institution3
Registered provider of social housing3
Residential care home3
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to communicate relevant patient information between GP and mental health services
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.6
Action
Implement an assessment service with designated referral administrators who request a Patient Profile from the GP for every Adult Mental Health Services referral.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Send patients and GPs written assessment outcomes describing the formulation and recommendations, with advice and signposting where secondary services are unsuitable.
Stated by Cornwall Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2018.
Action
Use a Community Mental Health Nurse Consultant to liaise with GP practices on assessment services, team responsibilities, information sharing and raising concerns.
Stated by Cornwall Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Work with the National Data Guardian to encourage appropriate information sharing by health and care practitioners.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Action
Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Written confirmation of assessment outcomes to GPs and ongoing liaison are considered sufficient for communication about referrals.
Stated by Cornwall Partnership NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Some information-sharing recommendations were beyond Devon Doctors’ control.
Stated by Devon Doctors GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
South Yorkshire (Western)
Concerns raised1
Failure of communication and information sharing between CAMHS and Adult Services
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.1
Action
Resolve governance and technical barriers to establish information exchange between CAMHS and adult emergency services.
Stated by Sheffield Children'S NHS Foundation Trust and Sheffield Health Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local commissioners and providers are responsible for ensuring timely information sharing, communication and joint working between mental health services.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Disjointed coordination of care between crisis house and crisis team services
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.3
Action
Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Introduce joint risk assessments completed by OneHousing and Camden and Islington staff.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 November 2017.
Action
Reinforce detailed feedback to OneHousing staff and agreement of a written action plan when crisis team staff complete risk assessments.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North West Wales
Concerns raised1
Delay in sending discharge information to the GP
This report raised 7 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.
London Inner (West)
Concerns raised1
Failure to coordinate pre-discharge handover and transition with the GP surgery
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.2
Action
Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.
Stated by South West London and St George'S Mental Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2017.
Action
Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.
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 3 October 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational concerns about discharge and communication are the responsibility of the relevant NHS Trust.
Stated by Jackie Doyle-Price MPRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Failure to communicate confirmed fractures and necessary care measures to relevant care providers
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.
South Wales Central
Concerns raised2
Failure to reliably communicate medication and clinical plans from hospital to care home
Fragile communication system between GP, hospital and care home
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.6
Action
Discuss with CSSIW how to collaborate and jointly address fragile communication between health services and the care home.
Stated by Healthcare Inspectorate WalesStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Action
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Action
Undertake a review of discharge arrangements, focusing on communication and documentation supporting discharge from secondary to primary healthcare.
Stated by Healthcare Inspectorate WalesStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2017.
Action
Fast-track medical records for new patients registering at nursing or care homes so doctors receive prior medical history promptly.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current inspection methodology was considered to cover the relevant care elements, so no additional policy change was required.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Delays in dispatching discharge summaries
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.3
Action
Deploy additional resources to clear the discharge-summary backlog and restore timely completion.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2017.
Action
Implement bespoke electronic casualty-card software to generate and send Emergency Department discharge summaries electronically in near real time.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2017.
Action
Strengthen discharge-summary governance through designated clinical and operational leadership, reiterated consultant accountability, compliance monitoring and ward-level safety-net alerts.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 July 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing discharge-summary safety mechanisms are considered sufficient to prevent recurrence of the identified individual human error.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Liverpool and the Wirral
Concerns raised1
Failure to ensure effective information exchange during mental health service transfers
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
Amend the transfer policy to require timely, comprehensive handover of information for CPA and non-CPA service users.
Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Circulate the inquest outcome and transfer-policy changes through operational management meetings, consultant forums and a Quality Practice Alert.
Stated by Mersey Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Consider including an audit of transfer processes in the Junior Doctor Audit programme.
Stated by Mersey Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 August 2017.
Manchester South
Concerns raised1
Limited information sharing between health professionals to identify service access and need for psychiatric referral
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.1
Action
Wrote to the mental health lead requesting improved communication between Healthy Minds and GPs.
Stated by Grosvenor Medical CentreStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
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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.
