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.
Inner North London
Concerns raised1
Failure to ensure communication between interventional radiology and hepatology specialists
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
Conduct regular documented MDT discussions between medical teams and interventional radiologists, including discussions for non-elective patients outside formal MDT meetings.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Further discussions with the referring team at the procedure stage would not have changed the procedure performed.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Lack of a clear communication strategy and treatment plan between DGHs and tertiary centres
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.
West Sussex
Concerns raised1
Failure to transfer important and accurate medical information to telecare and emergency services
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 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.
Worcestershire
Concerns raised1
Failure to pass important prisoner health and welfare letters to the prison healthcare team
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of communication of existing DNA-CPRs or Advance Care Plans between community paediatric teams and emergency 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 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.3
Action
Place alerts on the NWAS system for children with current advance care plans and review them when changed or at least annually.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2019.
Action
Review archived records for children with palliative care needs to identify advance care plans predating the electronic system and include them in alerts.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2019.
Action
Communicate current advance care plan information and provide child lists to relevant hospital children’s services to support replication of alert systems.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Reviewing and communicating changes to DNA-CPR decisions remains the responsibility of the patient’s referring clinician or GP practice.
Stated by North West Ambulance Service NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of communication between midwifery and social work teams
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised1
Failure to transmit donor kidney CMV status to the renal transplant team
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to communicate pregnancy information effectively on hospital arrival
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.6
Action
Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Develop a comprehensive cardiac-arrest handover procedure with tertiary centres to ensure key clinical information reaches receiving teams.
Stated by London Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Roll out the cardiac-arrest handover procedure and ATMIST AMBO tool to all receiving centres.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Assess the feasibility of adding a handover audit mechanism to the developing electronic patient care record specification.
Stated by London Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 October 2019.
Action
Include SBAR handover training in the Emergency Department junior doctors' induction.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2019.
Action
Design SBAR handover into electronic clinical notes used from patient presentation through discharge.
Stated by Whittington Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing SBAR handover tool is considered sufficient to help crews convey relevant information to emergency departments, including in stressful circumstances.
Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of private providers to obtain relevant clinical information from referring services
This report raised 10 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.
Birmingham and Solihull
Concerns raised1
Failure to pass reliable information between mental health services
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.6
Action
Roll out Liaison and Diversion staff access to the Spine for wider pan-mental-health information.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Meet BSMHT Trust leads to consider jointly strengthening communication pathways between services.
Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Implement MERIT access arrangements to enable cross-trust access to relevant mental-health records.
Stated by Black Country Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Develop a joint operating protocol with the Sandwell Liaison and Diversion Service for custody-based patient assessment.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Action
Advance the Local Integrated Health and Care Records programme to enable safe, secure sharing of comprehensive digital care records.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 26 July 2019.
Action
Produce and operationalise an information-sharing protocol for co-commissioned Armed Forces mental health services.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 July 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Other concerns concerned NHS bodies and services not provided by the respondent, so the respondent did not comment on those outcomes.
Stated by Black Country Healthcare NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Local NHS agencies are expected to address the report’s local concerns.
Stated by NHS EnglandRedirects 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.
