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 raised1
Failure to communicate outstanding investigations or treatment to police after a patient self-discharges
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leeds Teaching Hospitals NHS Trust
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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Leeds Teaching Hospitals NHS Trust
Clinicians could not identify a lawful public-interest justification to disclose medical information to police without the patient’s consent.
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Leeds Teaching Hospitals NHS Trust
Routine police contact after self-discharge is considered infeasible, unreasonable, time-consuming and likely to breach confidentiality unjustifiably.
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Leeds Teaching Hospitals NHS Trust
Existing arrangements provide relevant medical-information handovers when patients transfer to recognised facilities with trained medical or nursing staff.
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Concerns raised1
Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
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 send hospital discharge summaries electronically to GPs on the day of discharge
This report raised 10 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 ensure relevant prescribing information is received and communicated to drug services
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Greater Manchester Mental Health NHS Foundation Trust
- NHS England
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
Streamline receipt procedures for letters and faxes to reduce opportunities for them to be lost.
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NHS England
Send all GPs guidance on verifying receipt of urgent correspondence, documenting confirmation, and recording persistent suicide risk.
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NHS England
Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
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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Greater Manchester Mental Health NHS Foundation Trust
The service was unaware of the fax because the GP did not alert the recipient or confirm that it had been received.
-
Concerns raised1
Lack of effective communication between primary and secondary care services
This report raised 8 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 share clinically important information across mental health and primary care services
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Leicester City Council
- Leicestershire Partnership 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.5
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Leicester City Council
Implement next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.
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Leicester City Council
Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.
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Leicestershire Partnership NHS Trust
Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.
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Leicestershire Partnership NHS Trust
Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.
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Leicestershire Partnership NHS Trust
Require medical and nursing staff to notify GPs when patients miss outpatient appointments.
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Concerns raised1
Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cygnet Behavioural Health Limited
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
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Cygnet Behavioural Health Limited
Agree a protocol with St Thomas’ to improve communication and care coordination for patients referred to physical health clinics.
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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Cygnet Behavioural Health Limited
Responsibility for physical-health care after referral is transferred to St Thomas’ specialists, over whom the hospital has no control.
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Concerns raised1
Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
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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Department of Health and Social Care
The Department considers the concerns matters for local comment and resolution rather than national action.
-
Department of Health and Social Care
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
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Department of Health and Social Care
Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
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Concerns raised1
Failure to send discharge letters to GPs documenting dangerous treatment side effects
This report raised 1 other concern. 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 provide access to mental health information during medical treatment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Betsi Cadwaladr University LHB
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
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Betsi Cadwaladr University LHB
Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.
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Betsi Cadwaladr University LHB
Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026