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.
Manchester South
Concerns raised1
Failure of the MDT to effectively communicate agreed actions and recommendations for individual patients
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.1
Action
Continue implementing Cancer MDT Standards and auditing MDT communication and effectiveness across Greater Manchester.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Greater Manchester is the appropriate organisation to address local staffing and ineffective communication between the multidisciplinary team.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to communicate self-harm risks to emergency services searching for an absent patient
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.4
Action
Create and disseminate an SBARD aide-mémoire guiding staff escalation to police for patients absent from authorised leave or absconded, including Mental Health Act status and risk information.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Audit missing-person calls with Essex Police to assess the aide-mémoire’s effectiveness and establish and share further learning.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Action
Align Missing Persons Procedure B1601 with national guidance and require contact with BTP when suicide-risk information is marked on the PNC.
Stated by Essex PoliceStated completedThe respondent said that this action was complete when they made their response on 3 February 2023.
Action
Progress collaborative implementation of the national framework for adults missing from health and care settings through multi-agency planning and a Task and Finish group.
Stated by Essex PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2023.
Manchester South
Concerns raised2
Failure to document, track and act on inter-clinician communications
Lack of a recognised information-sharing pathway between community clinicians and secondary 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.1
Action
Raise information-sharing processes between community out-of-hours services and emergency departments with NHS England.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
Carmarthenshire and Pembrokeshire
Concerns raised1
Failure of communication and information sharing between Primary Mental Health Services and Tier 2 therapy providers
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to share dependence information with the mental health trust
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.1
Action
Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.
Stated by High Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
Dorset
Concerns raised1
Failure to ensure PPNs reach GPs for Dorset Council residents
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.8
Action
Review PPN-sharing processes with Dorset and BCP Adult Social Care partners to identify safeguarding risks and consistency improvements.
Stated by Dorset PoliceStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Action
Conduct a further review with Health and Social Care partners of PPN-sharing processes, using national best practice to identify improvements.
Stated by Dorset PoliceStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Review current PPN-sharing processes with Dorset Police and BCP Council to identify improvements.
Stated by Dorset CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Action
Amend Dorset Police and Dorset Council PPN-sharing processes to align with BCP processes.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Fund and recruit additional MASH staff to support sharing PPNs with GPs, with recruitment planned by the end of May 2022.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Meet with Dorset Police, BCP and health partners, including GP safeguarding leads, to discuss PPN-sharing processes and improvements.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Seek approval to align a partnership review of Adult MASH PPN sharing with the Children’s MASH review.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Amend the Adult Access Team process to forward PPNs to relevant agencies regardless of Adult Social Care involvement.
Stated by Dorset CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Police cannot share PPNs with GPs directly because it lacks access to the Dorset Care Record.
Stated by Dorset PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Dorset Council Adult Social Care staff will be responsible for sharing PPNs with GPs using the Dorset Care Record.
Stated by Dorset PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised1
Failure of communication and collaboration between primary and secondary 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.8
Action
Provide access to a medical consultant for clinical advice through the Flow Centre telephone line.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Launch direct-access telephone advice lines for urgent and outpatient queries through Consultant Connect.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Create a bypass-number directory enabling hospital teams to contact GP surgeries directly when immediately necessary.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Operate a Medical Examiner service with multidisciplinary panel review, including Primary Care input, to identify and review interface issues.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Send GPs weekly updates from the Deputy Medical Director about key information and changes to Secondary Care Services.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Provide GPs with intranet access to information on pathways, Secondary Care Services and advice lines.
Stated by Aneurin Bevan University LHBStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Explore primary–secondary care communication options, identify case-specific barriers, address them, and ensure clinical staff know the available routes.
Stated by The Richmond ClinicStated completedThe respondent said that this action was complete when they made their response on 20 January 2022.
Action
Continue cooperating with and positively engaging in the Health Board’s programme to facilitate primary–secondary care communication.
Stated by The Richmond ClinicStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
For community patients, the registered GP and Primary Care team have overall responsibility for medical care coordination.
Stated by Aneurin Bevan University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing clinical systems, letters, directories and switchboards provide GPs with sufficient access to hospital records, clinicians and support.
Stated by Aneurin Bevan University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester City
Concerns raised2
Inadequate and incomplete transfer and communication from inpatient care to the CMHT
Failure to make appropriate and regular GP contacts across inpatient care and discharge
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
Address coordination of diabetes management at discharge through the diabetes steering group.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 October 2021.
Action
Employ physical-health nurses within CMHTs to complete annual physical-health assessments and communicate results to GPs, with Trust monitoring.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 October 2021.
Action
Audit CMHT use of care-record interfaces for communication with GPs and share the audit and resulting action plan with the Trust audit committee.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing discharge CPA requirements in the CMHT procedure and clinical-record audits are relied upon to address discharge planning compliance.
Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing CPA policy requirements, staff supervision and annual audits are relied upon to monitor communication with GPs about physical health.
Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing shared-care-record systems, GP correspondence, supervision and audits are relied upon to support communication about service users’ physical health.
Stated by Greater Manchester Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester City
Concerns raised1
Inadequate transfer and communication from inpatient care to the HBTT
This report raised 9 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
Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
HBTT staff reviewed the patient before discharge and considered that the information needed to support transfer had been shared verbally.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to clearly convey community management advice and risks to community health professionals and families
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 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
Communicate appropriate advice and guidance to relevant providers to increase staff awareness of available materials.
Stated by NHS Greater Manchester Integrated Care BoardStatus unclearThe respondent did not make the status of this action clear when they made their response on 26 August 2021.
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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.
