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 information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
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.
Liverpool and the Wirral
Concerns raised1
Failure to send discharge letters to all current medical attendants
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual trusts remain responsible for discharge summaries and transferring medication information after discharge.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing legal and professional duties provide a sufficient framework for information sharing, so further data-sharing requirements are unnecessary.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of health and social care services to provide integrated care and share health information
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Suffolk
Concerns raised1
Failure to transfer the NHS 111 Service’s original disposition information to ambulance crews and treating clinicians
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.2
Action
Consult other ambulance trusts to share best practices and solutions for recording and transmitting patient disposition information.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Action
Draft and issue dispatch instructions specifying pertinent information, including NHS 111 disposition descriptions, for transmission to attending resources.
Stated by East of England Ambulance Service NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The organisation is not constituted to mandate or instruct individual ambulance services on local information-sharing processes.
Stated by Association of Ambulance Chief ExecutivesOutside remitThe respondent said that this matter was outside its role or authority.
Manchester North
Concerns raised1
Failure to respond to and action clinical information requests from the substance misuse service
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.4
Action
Promote wider uptake of Focussed Care across Oldham practices to support substance-use-related care.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Action
Complete a wide-ranging review of GP communication across all community substance misuse services.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Improve recording of GP communications in the electronic client records system.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Review and improve follow-up systems for requests to GPs for information.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A joint learning meeting with Turning Point would occur only if Oldham CCG supported it.
Stated by Hopwood House Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
London (East)
Concerns raised1
Failure to communicate changed asthma medication to primary care
This report raised 23 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.
Isle of Wight
Concerns raised1
Failure to provide timely Discharge Summaries to GPs
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.6
Action
Establish a Medical Director-led workstream to improve the quality and timeliness of discharge summaries.
Stated by Isle of Wight NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 May 2019.
Action
Conduct an in-depth review of discharge summaries and communications to GPs following relevant mental health contacts.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Map communication processes with staff groups and develop a standard operating procedure or flowchart.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Audit discharge-summary quality, including admission reasons, care received, and medication reviews or changes.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Use formal teaching sessions with junior doctors to embed learning from the discharge-summary audit.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Action
Present discharge-summary audit outcomes at Trust quality forums to share learning.
Stated by Isle of Wight NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 May 2019.
Manchester South
Concerns raised1
Failure to share admission and encounter information with wider mental health 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 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
Move alcohol liaison practitioners to Stepping Hill Hospital and integrate them into the all-age liaison mental health team.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 May 2019.
Manchester South
Concerns raised1
Failure to provide timely and accurately directed discharge information identifying the responsible paediatrician
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Delays in transferring critical mental health information between mental health services and GPs
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.5
Action
Establish Trustwide timescales and targets for completing GP letters.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
Action
Invest in electronic recording, listening devices, and hybrid mail to support timely GP correspondence.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
Action
Participate in developing and implementing Docman electronic mail links with local GP surgeries.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2018.
Action
Implement electronic GP correspondence through the Trust-wide Hybrid Mail rollout and Docman, supported by GP-practice IT infrastructure.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
Action
Implement monthly monitoring to ensure GP letters are issued within the nationally required two-week timescale.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Trustwide timescales, electronic recording, hybrid mail and management oversight are considered sufficient to address delays in completing GP letters.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Rapid information sharing across NHS providers requires a national solution beyond the Trust’s local systems and arrangements.
Stated by Birmingham and Solihull Mental Health NHS Foundation TrustRedirects 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.
