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 clearly record treatment plans between transferring and receiving clinical staff
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.2
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Action
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust -
Action
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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 existing Treatment Escalation Plan adequately specified escalation to acute hospital if deterioration occurred, despite omission from the handover form.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure of acute, alcohol and drug treatment, and mental health teams to share crucial risk information appropriately
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.4
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Action
Test and roll out CDDFT electronic patient-record access on TEWV clinicians’ laptops for joined-up assessments and information sharing.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust -
Action
Continue team discussions and daily MDT reminders about documenting and verbally handing over homelessness and other risk information.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust -
Action
Audit and deep-dive liaison documentation to verify that verbal handovers to other Trusts and services are recorded, addressing issues through supervision and team meetings.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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Action
Reissue an open letter to all staff supporting appropriate information sharing while balancing patient confidentiality and safety.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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Concerns raised1
Lack of consultation with receiving-prison healthcare teams about care capability
This report raised 16 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.1
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Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of access by café71 staff to mental health team information about patients’ backgrounds and risk factors
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
Audit referrals sent to Café 71 every six months and report findings through Acute Care and First Response governance meetings.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust
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
Café 71 does not operate in isolation; staff can obtain relevant mental-health information from Trust crisis-line staff with the individual’s consent.
Stated by Cheshire and Wirral Partnership NHS Foundation Trust
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Concerns raised1
Failure to notify support services of vulnerable patients' discharge
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
Update Symphony’s discharge screen to record discharge discussions and identify notifications or vulnerable-adult support needed before patients go home.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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 Emergency Department was not informed of any request or requirement to notify the Housing Officer about discharge.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to prepare discharge summaries only when patients are ready for discharge
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
Issue a safety instruction directing staff to take care when pre-populating discharge summaries and avoid prejudging investigation results.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Lack of communication between services for wound management
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.
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
Communicate Tissue Viability Nurse referral criteria and raise awareness of the service across the Trust through collaborative Quality Governance work.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Failure of NHS111 health advisers to access GP electronic summaries and background diagnoses
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.1
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Position
GP electronic summaries cannot be presented to non-clinical NHS 111 advisers because they lack the training and mandate to interpret clinical information.
Stated by NHS England
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Concerns raised1
Failure to provide community ultrasound reports and images to treating clinicians
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.
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
Continue transitioning providers from individual PACS systems to a central PACS system, including integration of acute provider trusts.
Stated by NHS Kent and Medway Integrated Care Board -
Action
Review the incident and diagnostic workflow, audit data-sharing systems, and produce and assess an options appraisal for process and IT integration improvements.
Stated by NHS Kent and Medway Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The first ultrasound report was inaccurate and should not have been sent to the patient’s GP.
Stated by NHS Kent and Medway Integrated Care Board
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Position
GPs receive community diagnostic reports, assess them clinically, and decide whether referral to secondary care is required.
Stated by NHS Kent and Medway Integrated Care Board
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Concerns raised1
Ineffective communication between community teams
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 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.
Data last updated 7 September 2026