“…Furthermore, information exchange may be thwarted by technical factors, such as unreliable IT systems or systems that do not ‘speak’ to one another, or by individual factors (e.g., a practitioner who does not realise the potential significance of a piece of information for another agency, or who is feeling too overwhelmed to read a referral carefully and follow it up), or any combination of these. A regular theme is the importance of discussion, not relying solely on written/digital referrals, to ensure information is properly understood, and a common criticism is that practitioners did not show an appropriate level of ‘professional curiosity’ or ‘challenge’ to ask for more information, or clarification of the information they have been given from families or other professionals (Dickens et al 2022c, 2023; Garstang et al 2023). But an individual's practice is shaped by their organisational context and culture (e.g., workloads, responsibilities, supervision, support), and whilst such factors are often mentioned, they are rarely applied rigorously to the analysis of what ‘went wrong’.…”