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 raised1
Failure of specialties to communicate about patients’ plans and actions
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.
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 discharge summaries to care homes
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.4
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Action
Remind Emergency Medicine clinicians to complete discharge summaries for every patient, including those discharged somewhere other than home.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Remind nursing staff to verify discharge-summary completion before patients leave the department.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Publish learning from the case in the January 2025 all-staff patient safety bulletin, emphasising complete and accurate discharge summaries at discharge.
Stated by Mid and South Essex NHS Foundation Trust
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Action
Monitor discharge-summary issuance through the 2025 trust-wide corporate audit programme and use findings to determine further action.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Unavailability of essential patient information to treating clinicians in new clinical settings
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.1
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Action
Publish national statutory hospital discharge guidance requiring safe, timely discharge and accurate information sharing across organisational boundaries.
Stated by Department of Health and Social Care
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Concerns raised2
Failure to communicate clinically relevant information between services about epilepsy and psychosis
Failure to send discharge summaries to the General Practitioner
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 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
Provide Neurology Department with electronic crisis assessments and outcome plans for service users receiving neurological treatment.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Include discharge summaries in annual service record-keeping audits to verify timely transmission to GPs and required quality standards.
Stated by Sheffield Health Partnership University NHS Foundation Trust
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Concerns raised1
Failure to share all relevant information with mental health practitioners in a timely manner
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 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
Operate the newly implemented Rapid Response Service through a single point of contact to support consistent guidance and information sharing with police.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Continue monitoring information sharing between the Trust and Sussex Police through the Rapid Response Service.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to provide treating clinicians with public health investigation feedback and infection-control information
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.
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
The expectation that UKHSA should disseminate information to clinicians and family was unfair because it did not reflect UKHSA policies or procedures.
Stated by UK Health Security Agency
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Concerns raised1
Difficulty obtaining collateral mental health information from other services
This report raised 11 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
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Action
Raise NHS Trust information-sharing failures between criminal justice pathways as a detainee welfare concern.
Stated by National Police Chiefs’ Council
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
Sussex Partnership Trust’s Mental Health Helpline is best placed to respond about family information not being shared with the commissioned Liaison and Diversion service.
Stated by NHS England
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Concerns raised2
Failure of probation oversight to ensure awareness and proper administration of mental health treatment requirements
Failure to transfer and communicate mental health treatment requirements to receiving Trusts
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
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Action
Collaborate with the Forensic and Specialist Directorate to examine Kent Secondary Care Mental Health Treatment Requirement practice and responsibilities across the intervention.
Stated by Probation Service
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Concerns raised1
Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians
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.1
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Action
Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Stated by 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.2
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Position
Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Stated by Department of Health and Social Care
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Position
Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to share information regarding deterioration in mental health with the appropriate team
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.1
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Action
Email Adult Mental Health Teams when online records are unavailable, follow up until a decision is received, and escalate unsuccessful contact to team leaders.
Stated by Oxfordshire County Council
Data last updated 7 September 2026