Recurring concern

Failure to communicate clinically important information reliably between care services

Get email alerts

Request correction

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
Individual concerns: 157
Date range: 2013–2026
Stated actions: 271

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

14 Mar2014
Leicester City and South Leicestershire
Concerns raised1
1. Failure to exchange prescription information between treatment services and the GP
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 4
1. Action
  Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.
  Stated by Leicestershire Partnership NHS TrustStated planned
2. Action
  Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.
  Stated by Leicestershire Partnership NHS TrustStated planned
3. Action
  Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.
  Stated by Leicestershire Partnership NHS TrustStated planned
1. Action
  Audit case notes for GP correspondence within 14 days and repeat the audit every six months.
  Stated by Leicestershire Partnership NHS TrustStated planned
AI-generated summary

Michael Anthony Tarratt · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to exchange prescription information between treatment services and the GP
Wider context from the report
“(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. ”
Source location
Michael Anthony Tarratt · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.

Verbatim wording from the response
“The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:”

Source location
2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 14 March 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.

Verbatim wording from the response
“I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

Source location
2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 14 March 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.

Verbatim wording from the response
“I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

Source location
2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 14 March 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit case notes for GP correspondence within 14 days and repeat the audit every six months.

Verbatim wording from the response
“A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.”

Source location
2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
Page 2 · response
Published 14 March 2014
Open published response
3 Jan2014
Gateshead and South Tyneside
Concerns raised1
1. Failure to communicate relevant postoperative risks and complications to community carers
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.
AI-generated summary

Keith Fleming · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Keith Fleming underwent elective reversal of an ileostomy in January 2013 and was discharged home on 14 January. He developed an unrecognised internal infection, was admitted as an emergency on 6 February, and died on 10 February 2013 despite urgent treatment. The substantive concerns included the absence of recorded temperature and blood pressure readings, insufficient monitoring and communication between surgical and community services, and inadequate care planning and record keeping after discharge.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate relevant postoperative risks and complications to community carers
Wider context from the report
“The General Practitioner and consequently the nursing staff were not aware of that the anastomosis of the bowel carried out during the original operation ( 2007) had dehised. Nor were they aware of an internal area of abscess adjacent to the repaired stoma site , only discovered on post mortem and together leading to a catastrophic infection within the deceased particularly and significantly in the area of his left buttock. The reality was the infection within the otherwise pelvic area had tracked through the pelvis into the area of the left buttock. It was the presence of the swelling of this area of the buttock which was to alert the deceased’ wife several days after his discharge home to the growing crisis and resulted in her summoning her husband’s GP Dr.████████. The Doctor immediately recognized the symptoms, arranged for the deceased’ emergency admission to the South Tyneside District Hospital. ”
Source location
Keith Fleming · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Dec2013
Central and South East Kent
Concerns raised1
1. Failure of effective oral and written communication between integrated care and district nursing services
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.
AI-generated summary

Michael Longley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Longley had an adverse reaction to Rivaroxaban administered after hip surgery. He was admitted to hospital with an unrecordable platelet count and died the same day; the report also identified difficulties in communication between Integrated Care 24 and the District Nursing Service.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of effective oral and written communication between integrated care and district nursing services
Wider context from the report
“I heard evidence that Integrated Care 24 had difficulties in contacted the District Nursing Service on 25th December 2011 and I consider that improved methods of both oral and written communication between IC24 and the district nurses must be put in place. ”
Source location
Michael Longley · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Sep2013
Avon
Concerns raised1
1. Inadequate communication between the neonatal intensive care and cardiac units
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 3
1. Action
  Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
2. Action
  Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.
  Stated by Bristol NHS Foundation TrustStated planned
3. Action
  Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.
  Stated by Bristol NHS Foundation TrustStated planned
AI-generated summary

Rose Jean COLES · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rose Coles was born prematurely at 34 weeks’ gestation and had congenital heart disease for which she received treatment. Evidence raised concerns about communication between the neonatal intensive care unit and cardiac unit, including whether the cardiac unit was suited to caring for premature babies and whether a protocol, checklist or improved communication would assist staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate communication between the neonatal intensive care and cardiac units
Wider context from the report
“Evidence was given about the communication between the neonatal intensive care unit and the cardiac unit. Concerns were raised that the cardiac unit were not suited to caring for premature babies and that a protocol or checklist or better communication between NICU and cardiac unit would be helpful to assist the doctors and indeed the nurses in caring for a premature baby on the cardiac ward. ”
Source location
Rose Jean COLES · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a structured cardiac transfer pack for use between the NICU and Cardiac Unit.

Verbatim wording from the response
“Improve formal communication between NICU and Cardiac Unit. | RIC | Develop Structured Cardiac Transfer Pack for use between two units. | ████████ | 30th November 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Circulate the NICU/BCH link consultant rota regularly to the Cardiac Unit.

Verbatim wording from the response
“| RIC | Confirm NICU/BCH link consultant through regular circulation of rota to cardiac ward. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide 24-hour telephone access to the NICU nurse in charge for Cardiac Unit staff seeking advice.

Verbatim wording from the response
“| RIC | Confirm NICU nurse in charge available 24 hours per day for telephone advice if requested to all cardiac ward staff. | ████████ | 28th October 2013”

Source location
2013-0245-Response-by-University-Hospital-Bristol
Page 2 · response
Published 27 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to exchange prescription information between treatment services and the GP

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

Concerns raised1

Failure to communicate relevant postoperative risks and complications to community carers

Concerns raised1

Failure of effective oral and written communication between integrated care and district nursing services

Concerns raised1

Inadequate communication between the neonatal intensive care and cardiac units

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

Actions described in response 4

Actions described in response 3