Recurring concern
Failure to communicate clinically important information reliably between care services
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Request correctionFirst reported 27 Sep 2013•Latest report 10 Jun 2026
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
- Individual concerns
- 157
- Date range
- 2013–2026
- Stated actions
- 271
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Migrate records to a new platform and train staff to support timely, complete recording and mobile working.
Stated by London Borough of Camden -
Action
Introduce an emergency-services referral checklist requiring Careline to provide London Ambulance Service with the caller’s full history.
Stated by London Borough of Camden -
Action
Develop information-sharing arrangements with London Ambulance Service.
Stated by London Borough of Camden
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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Position
Calls not resulting in a Careline visit are not routinely passed to response officers because no action from them is required.
Stated by London Borough of Camden
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Position
Wellbeing coordinated the responses, and there was no evidence that the individual lacked capacity or required mental-health intervention.
Stated by London Borough of Camden
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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.
Responses linked to these concernsEach 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
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Action
Maintain a 24-hour referral service and dedicated pathway with the Inclusion Service.
Stated by Hampshire Hospitals NHS Foundation Trust -
Action
Maintain telephone and onsite liaison with Inclusion regarding referrals and referred patients receiving inpatient care.
Stated by Hampshire Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing referral, liaison, follow-up and high-intensity-user arrangements are considered sufficient to address the reported concerns.
Stated by Hampshire Hospitals NHS Foundation Trust
-
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach 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
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Action
Develop GP access to mental health records.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Embed GP communication requirements in acute and community mental health team procedures, instruct managers, and monitor compliance after referral triage.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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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Position
Including hospital blood results in discharge summaries is not considered necessary because GPs can access those results through Telepath.
Stated by Epsom and St Helier University Hospitals NHS Trust
-
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.
Responses linked to these concernsEach 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
Require verbal nurse handover alongside written handover when transferring patients between hospitals.
Stated by University Hospitals of North Midlands NHS Trust
-
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.
Responses linked to these concernsEach 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
Review the case with the practice to identify further learning.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
Stated by NHS Greater Manchester Integrated Care Board
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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.
Responses linked to these concernsEach 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
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Action
Implement the SBAR communication framework for clinical handovers.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Develop and seek regional agreement for a maternity-specific SBAR handover model.
Stated by East Midlands Ambulance Service NHS Trust -
Action
Implement the maternity-specific SBAR handover model across the EMAS footprint.
Stated by East Midlands Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
The HSIB cannot investigate this case because it occurred before the organisation became operational and falls outside its investigation criteria.
Stated by Health Services Safety Investigations Body
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Position
Operational concerns are for the involved NHS trusts to address.
Stated by Department of Health and Social Care -
Position
HSIB cannot investigate incidents occurring before its establishment because they do not meet its investigation criteria.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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 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.
Responses linked to these concernsEach 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
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Action
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Identify patients with significant forensic histories in AMIGOS special notes to inform care and discharge planning.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce the approved PARIS electronic clinical record system across Manchester services.
Stated by Greater Manchester Mental Health NHS Foundation Trust
Data last updated 7 September 2026