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.
Surrey
Concerns raised1
Breakdowns in communication between inpatient staff and the CMHT
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 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.
Essex
Concerns raised1
Failure to provide continuity and handover between hospital and community psychology services
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
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Regularly audit handovers to verify safe transfer of psychological care to community teams.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Review the operational model for transitions and handovers between inpatient and community psychological services.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
Action
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Lack of access to essential patient records before mental health liaison assessment and treatment
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
Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Action
Advise agency staff during local induction how to access, review and update hospital records through permanent team members.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Newcastle and North Tyneside
Concerns raised2
Failure to communicate accurate clinically important information between clinicians and departments
Failure of telephone referrals and imaging summaries to provide accurate, consistent clinical information
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.7
Action
Participate in a regular Inflammatory Bowel Disease multidisciplinary team meeting at Newcastle to improve communication and advice between the Trusts.
Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
Action
Relaunch SBAR across the Trust, requiring documented email confirmation and record copies for telephone advice and escalation communications.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2023.
Action
Hold joint internal and cross-Trust IBD multidisciplinary meetings at established biweekly and triweekly frequencies.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
Action
Operate the ratified CT imaging referral protocol requiring senior review, written ICE referrals and defined Radiographer authorisation pathways.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
Action
Develop and deliver diagnostic-referral education covering mandatory fields, clinical information and differential diagnoses for trained staff.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2023.
Action
Require ICE referrers to record clinical details and differential diagnoses in the renamed mandatory referral field.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
Action
Remind Radiology staff to document relevant justification discussions in RIS for access by subsequent reporting Radiologists.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Timetabled multidisciplinary team meetings cannot determine acute or emergency care because those decisions cannot be delayed.
Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Written ICE referrals are generally sufficient to justify imaging without supplementary telephone discussion with a radiologist.
Stated by North Cumbria Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Worcestershire
Concerns raised1
Failure to communicate concerns about continued unsafe sling use in writing to care agencies
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 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
Implement and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
Stated by Bluebird Care (Bromsgrove & Redditch)Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure of inter-trust referral systems to provide timely electronic transfer of clinical information, images and notes
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
Explore extending referral-platform benefits to other Greater Manchester services.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Discuss with information officers and the Digital Delivery Executive how to develop the referral-platform proposal into a funded project.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Milton Keynes
Concerns raised1
Failure to accurately transcribe communications received at emergency department triage
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.
Swansea and Neath Port Talbot
Concerns raised1
Lack of integrated electronic access to medical and treatment records between treating teams
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
Enable two-way WCCIS information sharing between Swansea community mental health and drug and alcohol teams.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Further WCCIS rollout is on hold pending Welsh Government approval of National Programme Team recommendations.
Stated by Swansea Bay University Local Health BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Local Authority must request and implement any amendments to WCCIS system functionality.
Stated by Swansea Bay University Local Health BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Omission of pertinent psychiatric history from GP summaries
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.
South London
Concerns raised1
Lack of a national risk-flagging system for previous self-harm attendances
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.
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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.
