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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 67 reports
See individual reports that have raised this concern, and the actions taken in response
Cornwall and Isles of Scilly
Concerns raised1
Lack of clear, detailed and direct doctor-to-doctor handovers between hospitals
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Cornwall Partnership NHS Foundation Trust
Royal Cornwall Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Limited medical cover makes it infeasible to require doctor-to-doctor handovers for all admissions to nurse-led community hospital wards.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Nurse-to-nurse handover, admission refusal safeguards and occasional doctor handovers are considered sufficient for community hospital admissions.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Dorset
Concerns raised1
Lack of national guidance for healthcare handover to receiving prisons
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Lancashire and Blackburn with Darwen
Concerns raised1
Inadequate nursing handovers failing to ensure appropriate risks are managed and prioritised
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
East Lancashire Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
East Lancashire Hospitals NHS Trust
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
East Lancashire Hospitals NHS Trust
Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.
East Lancashire Hospitals NHS Trust
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Nottinghamshire
Concerns raised1
Failure to routinely document handovers and key staff conversations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sherwood Forest Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Sherwood Forest Hospitals NHS Foundation Trust
Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.
Sherwood Forest Hospitals NHS Foundation Trust
Review medical documentation and audit nursing records, providing feedback, education and support where required.
Nottinghamshire
Concerns raised1
Insufficient and ineffective handover between medical staff
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sherwood Forest Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Sherwood Forest Hospitals NHS Foundation Trust
Assign the Tier 3 or above doctor to lead specialty and shift-change handovers for children’s care.
Cornwall and Isles of Scilly
Concerns raised1
Failure of handover from critical care to surgical teams to convey significant events and clinical status
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Plymouth NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
University Hospitals Plymouth NHS Trust
Review current intensive care-to-theatre transfer and handover practice.
University Hospitals Plymouth NHS Trust
Create a pre-operative handover checklist for complex intensive care patients, covering airway, allergies, medications, clotting, blood products and other relevant care information.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
University Hospitals Plymouth NHS Trust
The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
University Hospitals Plymouth NHS Trust
Existing pre-operative assessment, intensive-care access and theatre briefing arrangements address relevant information-sharing needs, alongside a narrower new checklist.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to communicate and understand acute clinical information in consultant handover
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University College London Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
University College London Hospitals NHS Foundation Trust
Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
South Yorkshire (Western)
Concerns raised1
Failure of discharge reports to provide sufficient diagnostic and risk-trigger information for accurate handover
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Sheffield Health Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Sheffield Health Partnership University NHS Foundation Trust
Complete and audit discharge-summary and safety-netting practice, and review existing discharge templates.
Sheffield Health Partnership University NHS Foundation Trust
Complete and launch a new electronic discharge template, supported by local best-practice training.
Sheffield Health Partnership University NHS Foundation Trust
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Sheffield Health Partnership University NHS Foundation Trust
Include accurate, complete medical discharge-summary requirements in the medical staff rotation training programme.
Sheffield Health Partnership University NHS Foundation Trust
Instruct inpatient Responsible Clinicians to record diagnoses in Insight for inclusion in discharge summaries.
Sheffield Health Partnership University NHS Foundation Trust
Audit clinical record keeping, including risk assessments and discharge summaries.
Sheffield Health Partnership University NHS Foundation Trust
Review the format and function of discharge summaries to include early warning signs of deterioration.
Sheffield Health Partnership University NHS Foundation Trust
Incorporate the revised discharge-summary format into the new Rio electronic patient record system.
Derby and Derbyshire
Concerns raised1
Inadequate handover of treatment plans during transfer of care
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Inadequate handover during resuscitation emergencies
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.