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.
Cardiff & the Vale of Glamorgan
Concerns raised1
Failure to transmit relevant medical microbiology information to the accepting transplant centre
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.2
Action
Develop and implement an electronic system for specialist nurses to record and transmit donor data to transplant centres.
Stated by NHS Blood and TransplantStated plannedThe respondent said that this action was planned when they made their response on 18 December 2014.
Action
Continue reminding specialist nurses to capture and provide key donor information accurately and fully during the interim period.
Stated by NHS Blood and TransplantStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The microbiology results were unavailable before the transplant decision and therefore could not have affected the decision to transplant.
Stated by NHS Blood and TransplantDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Blackpool and the Fylde
Concerns raised1
Failure to communicate clinical assessment information between relevant specialist teams
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to report post-discharge patient contact to the responsible consultant in a timely manner
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
Recirculate the medical escalation flow chart to CHITT and inpatient staff to clarify escalation routes for risk concerns.
Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2014.
Blackpool and the Fylde
Concerns raised2
Failure to exchange sufficient relevant mental health information during cross-area transitions
Failure to confirm mental-health treatment information with the responsible hospital care team before prescribing medication
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.1
Action
Request written confirmation from the Consultant Psychiatrist or Community Nurse Practitioner for future prescription changes.
Stated by MDU Services LimitedStated plannedThe respondent said that this action was planned when they made their response on 27 November 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The prescription was not based solely on verbal patient information; the relevant hospital office was contacted to verify recommendations.
Stated by MDU Services LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Shropshire, Telford and Wrekin
Concerns raised1
Failure to send discharge summaries to patients’ GPs
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.
Suffolk
Concerns raised1
Failure to obtain relevant medical information for care planning during initial reception assessment
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.
South Yorkshire (Western)
Concerns raised1
Failure of two-way communication about prescribing 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West London
Concerns raised1
Failure to communicate medication changes between the GP practice and responsible clinician
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.5
Action
Review processes for recording medications across different healthcare sectors.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust considered its communication systems effective in this case and did not identify a need to change them.
Stated by Central and North West London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to provide out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes
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
Seek formal assurance from Mastercall on new-starter processes and contingencies for practitioners without NHS Smartcards.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 April 2014.
Action
Map and analyse shared-record access processes and systems with Mastercall to identify and mitigate further risks.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 April 2014.
Action
Work with Mastercall to provide fit-for-purpose mobile access to relevant patient information at the point of care through a governed improvement project.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 8 April 2014.
Brighton and Hove
Concerns raised1
Failure to communicate discharge information to receiving care providers and family
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
Provide ward nurses with refresher training on discharge processes, required documentation and Do Not Attempt Cardio-pulmonary Resuscitation forms.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.
Action
Emphasize completion of nurse-to-nurse discharge summaries for patients transferred to or returning to residential or nursing home care.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 April 2014.
Action
Conduct monthly snapshot audits of ward medical records to monitor discharge-documentation standards.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2014.
Action
Develop new discharge-planning paperwork to facilitate timely documentation and daily consideration of patients’ progress toward discharge.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The discharge process was not fundamentally flawed; shortcomings arose from inadequate implementation on this occasion.
Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
