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.
City of London
Concerns raised1
Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
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.1
Action
Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
Stated by South London and Maudsley NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Gwent
Concerns raised1
Failure of communication between hospital and community dietetic teams
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.16
Action
Implement a joint communication protocol for shared-care patients across hospital and community dietetic services.
Stated by Velindre NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Continue monthly joint dietetic professional meetings with Aneurin Bevan University Health Board.
Stated by Velindre NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Complete ratification and implementation of the multidisciplinary team checklist for complex nutritional care patients.
Stated by Velindre NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Audit the multidisciplinary team checklist and share learning through quality and safety governance.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Use the interim shared-care transfer document for transfers between Velindre Cancer Service and Aneurin Bevan University Health Board.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Engage with Welsh dietetic leaders to strengthen cross-boundary referral and patient handover processes.
Stated by Velindre NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Replicate pathway, communication and transfer safety processes across all health boards commissioned to provide services to Velindre Cancer Service.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Maintain read-only Clinical WorkStation access for all Velindre dietitians as part of routine practice.
Stated by Velindre NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 October 2025.
Action
Formalise digital access arrangements across all health boards commissioned to provide services to Velindre Cancer Service.
Stated by Velindre NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Develop a joint transfer-of-care standard operating procedure defining referral, handover, documentation, response-time and professional-contact requirements.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Action
Provide interim cross-organisational read-only clinical-record access for relevant dietitians.
Stated by Aneurin Bevan University LHBStatus at responseThe respondent said that this action was partly complete when they made their response on 9 October 2025.
Action
Grant appropriate ABUHB dietitians access to WCP clinical records.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Hold quarterly joint dietetic-lead meetings to review shared cases, incidents, communication issues and process improvement.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Conduct annual joint audits of adherence to the transfer-of-care standard and assessment protocol, reporting findings through governance groups.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Log communication deficiencies through Datix, review them jointly and feed identified learning into professional development.
Stated by Aneurin Bevan University LHBStated plannedThe respondent said that this action was planned when they made their response on 9 October 2025.
Action
Maintain joint monitoring meetings to review action-plan progress, share learning and resolve cross-boundary issues.
Stated by Aneurin Bevan University LHBStated in progressThe respondent said that this action was in progress when they made their response on 9 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The actions taken are considered robust enough to prevent future deaths related to dietetic support and provision.
Stated by Velindre NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to communicate pacemaker extraction referral requirements between specialist and local cardiology services
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
Develop structured Emergency Department discharge communications and built-in referral reminders, while reviewing amendments to the current Emergency Department notes.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 29 September 2025.
Action
Improve Emergency Department HIVE discharge workflows so staff can send discharge letters to relevant healthcare providers, including external cardiology departments.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Develop HIVE tip sheets and video guides on using the Emergency Department discharge navigator’s correspondence function and share them with relevant staff.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Build the HIVE discharge navigator so the correspondence workflow appears in the Emergency Department’s Dispo section.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
Action
Reinforce with Cardiology the importance of communicating with other secondary and tertiary care providers to maximise continuity of care.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Provide Cardiology Residents with focused training on copying inpatient discharge letters to relevant healthcare providers and referring patients to available pacemaker extraction services.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 September 2025.
East London
Concerns raised1
Failure to send relevant results and discharge summaries to the GP in time for appointments
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.1
Action
Provide junior doctors with dedicated administration time to check results and communicate them to patients and GP practices.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Northumberland
Concerns raised2
Failure to transfer comprehensive discharge and ongoing treatment information to community nursing services
Failure of hospital systems to enable electronic referrals to community nursing services outside the usual geographical area
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 lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 May 2025.
Action
Develop and implement the national Booking and Referral Standard to digitise and standardise referrals and bookings across care settings.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Interoperability configuration and management are assigned to local provider organisations and regional centres, rather than being led nationally by NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Riding and Hull
Concerns raised1
Failure of GP out-of-hours surgeries to access key GP medical history information after patient consent
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
Support greater integration and awareness of record sharing between in-hours and out-of-hours providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Work with the Shared Care Records Programme to support wider access to relevant patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Scrutinise providers’ handling of correspondence, clinical coding, information sharing, patient pathways and significant-event learning during inspection and monitoring activity.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Migrate clinical IT from EMIS to TPP SystmOne and enable GP Connect to support consent-based access to medical summaries.
Stated by Holderness HealthStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Highlight the concerns to the Professional Record Standards Body regarding interoperability.
Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Dictating providers’ computer systems and IT infrastructure is outside CQC’s role and remit.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Decisions about providers’ computer systems and IT infrastructure are a commissioning matter, not under CQC’s direct control.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The remote surgery was not a significant or currently active problem and therefore would not generally appear in GP Connect’s limited summary.
Stated by Holderness HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Making all GP IT systems identical is not possible because government policy promotes plurality among GP IT providers.
Stated by Royal College of General PractitionersDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
NHS England owns the interoperability strategy and GP Connect, so responsibility for this work lies with NHS England.
Stated by Royal College of General PractitionersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gateshead and South Tyneside
Concerns raised1
Failure of multiple clinical systems to support safe transfers of care
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
Establish the Single Patient Record to unify patient data and provide clinicians with accessible patient information.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Each provider organisation is responsible for sharing information across different digital systems through its established local digital governance processes.
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
Failure to provide consistent and accurate communication about patient care
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.1
Action
Use the incident as a learning opportunity to improve staff communication, ensuring information given to visiting professionals is accurate and understood.
Stated by Acorn Lodge Care CentreStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Care home staff were already confident and competent to communicate with professionals during emergencies, limiting the need for further competency measures.
Stated by Acorn Lodge Care CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Failure to share vital mental health information
This report raised 8 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
Develop and expand the Shared Care Record to provide unified access to patient information across partner services.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Disseminate Shared Care Record notifications, guidance and videos to emergency department clinical staff during rollout.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Implement the NOVA unified electronic patient record across acute, community and mental health services.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Action
Develop a unified electronic patient record across EPUT and MSEFT, including bidirectional primary-care integration.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 February 2025.
Devon, Plymouth and Torbay
Concerns raised1
Failure to achieve clear communication of key information with other agencies involved in patient care
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
Adopt SystmOne electronic patient records to enable consent-based information sharing between primary and secondary mental health services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 7 February 2025.
Action
Review and implement a process for sharing annual clozapine health-check outcomes with mental health services.
Stated by Pembroke Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Clinical discussions with prescribers and care delivered by the Trust fall outside the regulator’s remit, so it cannot directly address them.
Stated by Medicines and Healthcare products Regulatory AgencyOutside remitThe respondent said that this matter was outside its role or authority.
Position
Devon Partnership NHS Trust is responsible for improving internal and cross-agency communication, so no direct response is provided.
Stated by NHS Devon Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
