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 to communicate outstanding investigations or treatment to police after a patient self-discharges
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.3
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Position
Clinicians could not identify a lawful public-interest justification to disclose medical information to police without the patient’s consent.
Stated by Leeds Teaching Hospitals NHS Trust
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Position
Routine police contact after self-discharge is considered infeasible, unreasonable, time-consuming and likely to breach confidentiality unjustifiably.
Stated by Leeds Teaching Hospitals NHS Trust -
Position
Existing arrangements provide relevant medical-information handovers when patients transfer to recognised facilities with trained medical or nursing staff.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
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 send hospital discharge summaries electronically to GPs on the day of discharge
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 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 ensure relevant prescribing information is received and communicated to drug 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.
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
Streamline receipt procedures for letters and faxes to reduce opportunities for them to be lost.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Send all GPs guidance on verifying receipt of urgent correspondence, documenting confirmation, and recording persistent suicide risk.
Stated by NHS England -
Action
Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
Stated by NHS England
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 service was unaware of the fax because the GP did not alert the recipient or confirm that it had been received.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Lack of effective communication between primary and secondary care 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 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 clinically important information across mental health and primary care 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 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.5
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Action
Implement next-working-day telephone and two-day written feedback from AMHP assessments to relevant GPs.
Stated by Leicester City Council -
Action
Remind Adult Mental Health social workers to share relevant information with the full multidisciplinary team and carers.
Stated by Leicester City Council -
Action
Require staff to include referrals to other agencies in discharge letters and communicate them clearly to patients and carers.
Stated by Leicestershire Partnership NHS Trust
-
Action
Review and approve a revised Discharge Policy with detailed electronic discharge-letter requirements.
Stated by Leicestershire Partnership NHS Trust -
Action
Require medical and nursing staff to notify GPs when patients miss outpatient appointments.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Failure to establish dialogue between specialist physicians and psychiatrists about managing OSA risks
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
Agree a protocol with St Thomas’ to improve communication and care coordination for patients referred to physical health clinics.
Stated by Cygnet Behavioural Health Limited
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
Responsibility for physical-health care after referral is transferred to St Thomas’ specialists, over whom the hospital has no control.
Stated by Cygnet Behavioural Health Limited
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Concerns raised1
Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
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.3
-
Position
The Department considers the concerns matters for local comment and resolution rather than national action.
Stated by Department of Health and Social Care
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Position
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
Stated by Department of Health and Social Care -
Position
Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to send discharge letters to GPs documenting dangerous treatment side effects
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.
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 access to mental health information during medical treatment
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.2
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Action
Allocate a named care coordinator or nurse within 24 hours and require medication review and continuity of contact during transfers.
Stated by Betsi Cadwaladr University LHB -
Action
Improve communication between transferring mental health wards and receiving acute hospitals, including transfer of mental health medical records.
Stated by Betsi Cadwaladr University LHB
Data last updated 7 September 2026