Recurring concern

Failure to communicate clinically important information reliably between care services

First to latest report 27 Sep 2013 — 10 Jun 2026

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.

Reports and published responses 144 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Leicester City and South Leicestershire

    AI-generated summary

    Michael Anthony Tarratt · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to exchange prescription information between treatment services and the GP

    Wider context from the report

    “(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. ”

    Source location

    Michael Anthony Tarratt · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.

    Verbatim wording from the response

    “The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit case notes for GP correspondence within 14 days and repeat the audit every six months.

    Verbatim wording from the response

    “A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response

  2. Gateshead and South Tyneside

    AI-generated summary

    Keith Fleming · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to communicate relevant postoperative risks and complications to community carers

    Wider context from the report

    “The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock. It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital. ”

    Source location

    Keith Fleming · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Central and South East Kent

    AI-generated summary

    Michael Longley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of effective oral and written communication between integrated care and district nursing services

    Wider context from the report

    “I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place. ”

    Source location

    Michael Longley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Avon

    AI-generated summary

    Rose Jean COLES · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate communication between the neonatal intensive care and cardiac units

    Wider context from the report

    “Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”

    Source location

    Rose Jean COLES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

    Verbatim wording from the response

    “Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

    Verbatim wording from the response

    “| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

    Verbatim wording from the response

    “| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

    Source location

    2013-0245-Response-by-University-Hospital-Bristol
    Page 2 · response
    Published 27 September 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026