First reported 27 Nov 2013•Latest report 10 Jun 2026
Definition
What this concern includes
Includes failures of clinical handovers between healthcare staff, teams, wards or hospitals where the handover process is intended to transfer patient information, risks, concerns, responsibilities or required actions for safe ongoing care, including inadequate content, unclear standards, omission of key information, ineffective challenge and poor risk prioritisation.
Not included
Excludes non-clinical handovers, such as fire-and-rescue incident-role handovers or transport crew drop-off and pick-up handovers.
Excludes failures limited to retaining, reviewing or acting on information after an otherwise adequate clinical handover, unless the handover process itself is also deficient.
Excludes generic communication, staffing, training or documentation deficiencies not directly tied to a clinical handover.
Excludes the narrower shift-handover process where the assertion is confined to shift-change handover and does not support the wider clinical-handover condition.
Excludes failures of a separately named pathway or system where that pathway provides the more specific supported parent boundary.
Reports
67
Distinct published reports
Individual concerns
74
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
107
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 Care12
NHS England7
Care Quality Commission5
National Institute for Health and Care Excellence4
Tameside and Glossop Integrated Care NHS Foundation Trust3
Cwm Taf Morgannwg University Local Health Board2
General Medical Council2
Greater Manchester Mental Health NHS Foundation Trust2
HM Prison and Probation Service2
Mid and South Essex NHS Foundation Trust2
Nursing and Midwifery Council2
Pennine Acute Hospitals NHS Trust2
Royal College of Obstetricians and Gynaecologists2
Royal College of Paediatrics and Child Health2
Royal Cornwall Hospitals NHS Trust2
NHS trust45
Healthcare site15
Ministerial department13
Executive non-departmental public body11
Health and social care service regulator5
Integrated care board5
Local health board4
Private limited company4
Type not available4
Executive agency3
Health and care professional regulator2
Health professional body2
Professional body2
Company limited by guarantee1
Education sector body1
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.
Manchester South
Concerns raised1
Lack of a structured cross-team handover from ED to speciality departments
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Incomplete recording of medical-team handovers
This report raised 5 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.
Dorset
Concerns raised2
Failure to ensure accurate and complete handover information
Lack of written national guidance for handovers across healthcare settings
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.11
Action
Strengthen Good medical practice standards on continuity of care, information sharing, safe delegation and handover responsibilities.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Analyse consultation responses on Leadership and management and Raising concerns guidance.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Develop updated Leadership and management and Raising concerns guidance following the consultation.
Stated by General Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Deliver outreach talks and workshops supporting implementation of professional standards, including communication, teamwork, information sharing and patient safety.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Explore opportunities to promote handover, continuity of care, teamwork and communication expectations through Outreach when promoting updated guidance.
Stated by General Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Publish a guideline recommending structured patient handovers during transitions of care for adults receiving emergency and acute medical care.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Publish a quality standard requiring structured patient handovers during transitions of care for adults admitted with a medical emergency.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Develop and take SBAR-based inpatient handover guidance through internal governance.
Stated by Dorset Healthcare University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Prioritise a robust, accurate, live handover function in the pan-Dorset electronic health record planned for 2028.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Scope handover processes across all mental health inpatient units by June 2026 to identify required changes.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Audit handover-related incidents across inpatient wards, report findings through governance groups, and monitor progress quarterly through March 2027.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
Existing guidance from the NMC, GMC, NHS England and CQC is sufficient, so further NICE guidance on handovers is unlikely to improve safety.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The NMC is responsible for responding to concerns about incorrect information handed over during a previous patient transfer.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An additional general recommendation to include all pertinent information in written handover sheets is unlikely to be effective.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
Position
Existing professional standards adequately address communication, handover, record keeping, risk escalation and safe transfer of care.
Stated by Nursing and Midwifery CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Clinical standards and clinical advice on handovers fall outside the respondent’s professional-regulatory functions.
Stated by General Medical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
Clinical standards and advice on handovers are assigned to bodies such as NICE, government health departments and medical royal colleges.
Stated by General Medical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Detailed handover guidance for every healthcare facility would be impractical for a central organisation and unsuitable for differing local contexts.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
National bodies are responsible for issuing any future community and mental health handover guidance.
Stated by Dorset Healthcare University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Yorkshire and York
Concerns raised1
Failure to routinely check for patients' choking risks during handovers
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
Maintain a sip-testing procedure and staff training, with Speech and Language Therapy referral after failed tests.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2025.
Action
Roll out Nervecentre with prominent alerts for recorded swallowing difficulties and recommended texture-modified diets.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2025.
Action
Issue a clinical alert reinforcing explicit handover of known high-impact risks and documentation of verbal handover content.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Action
Review and update handover protocols where appropriate to reflect contemporary practice and learning from the case.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Action
Incorporate case learning into the monthly Patient Safety Bulletin and support local educational sessions for clinical staff.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Emergency Department action for swallowing or choking risks is limited by patients’ clinical needs and what is operationally deliverable in a busy department.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.
Stated by Yorkshire Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Routine verbalisation of choking risk for every patient is not operationally deliverable or proportionate and could cause information overload and missed pertinent details.
Stated by Yorkshire Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Inaccurate handover communications for patients returning from HDU to the main ward
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.3
Action
Use an updated ICU/HDU-to-ward discharge checklist requiring dual signatures from the transferring and receiving nurses, with implementation auditing.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Require ICU and receiving ward nurses to attend the first post-transfer observations and audit those observations as part of the safety strategy.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Hold weekday multidisciplinary transfer meetings to identify suitable ICU step-down patients, support core-hours transfers and prompt ward communication when beds become available.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Stockport NHS Foundation Trust is responsible for responding to concerns about handover communications at Stepping Hill Hospital.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Norfolk
Concerns raised1
Lack of clinical handover to receiving wards
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.4
Action
Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Introduce the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Worcestershire
Concerns raised1
Absence of a formal, documented handover system between hospital and Neighbourhood Team
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.2
Action
Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
Essex
Concerns raised1
Failure to communicate key information during staff handovers
This report raised 15 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.4
Action
Provide structured handover guidance using SBAR and SHARING tools to improve communication of critical information between maternity teams.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Teach and practise SBAR escalation during annual multidisciplinary PROMPT training.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Launch the RCOG escalation toolkit, including AID language, conflict-resolution teaching and team-of-shift handover practices.
Stated by Mid and South Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2024.
Action
Continue escalation work and audit compliance with expected communication standards.
Stated by Mid and South Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 December 2024.
Suffolk
Concerns raised2
Lack of directly compatible ambulance and hospital IT systems for immediate availability of clinical information
Failure of patient handover processes to ensure significant clinical findings are available to receiving clinicians
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
Develop IT support linking ambulance and emergency department systems to improve electronic clinical information sharing.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2024.
Action
Roll out an ambulance dataset linking ambulance-service and emergency-department data through the emergency care data set.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Local process improvements and ambulance information systems provide an adequate response to clinical handover and patient-record concerns.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Implementation and oversight of clinical handover protocols across England are the responsibility of local organisations.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Failure to provide a rapid and secure handover of unfinished work when practice workload cannot be managed
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
Disseminate guidance to all GP practices on options for discussing and handing over cases of concern, including standalone communication and website publication.
Stated by Cumbria Health LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Action
Pass triaged cases requiring same-day clinical input after closure directly to Cumbria Health by telephone.
Stated by Carlisle HealthcareStated plannedThe respondent said that this action was planned when they made their response on 30 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing information-sharing and clinical handover processes are considered sufficient to mitigate communication risks between healthcare organisations.
Stated by Cumbria Health LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures of clinical handovers between healthcare staff, teams, wards or hospitals where the handover process is intended to transfer patient information, risks, concerns, responsibilities or required actions for safe ongoing care, including inadequate content, unclear standards, omission of key information, ineffective challenge and poor risk prioritisation.
