Most serious case reviews flag the issue of inadequate information sharing and ineffective work with colleagues and other agencies.
The knowledge held by an individual practitioner or agency may not, on its own, appear worrying but when collated the overall picture may indicate a more significant level of concern and risk. Practical barriers to information sharing include using different and incompatible IT systems or even paper systems; and diverse interpretation of policy, procedure and protocol which prevent effective information sharing.
A number of SCRs identified GPs’ uncertainties about levels of concern that should prompt a referral, and also how to escalate concerns when a referral has been dealt with inadequately. In some cases there was reluctance on the part of health professionals to challenge social workers on the presumption that they know best, as well as a tendency to give up and not persist in flagging ‘niggling concerns’ because of the difficulties and complications of multi-agency work.