Recurring concern
Unreliable clinical handover processes
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Request correctionFirst reported 27 Nov 2013•Latest report 10 Jun 2026
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
- Individual concerns
- 74
- Date range
- 2013–2026
- Stated actions
- 107
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust -
Action
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Limited medical cover makes it infeasible to require doctor-to-doctor handovers for all admissions to nurse-led community hospital wards.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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Position
Nurse-to-nurse handover, admission refusal safeguards and occasional doctor handovers are considered sufficient for community hospital admissions.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach 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
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Action
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
Stated by East Lancashire Hospitals NHS Trust -
Action
Provide daily multidisciplinary meetings and twice-daily medical-team handovers to the Acute Care Team to identify concerned patients and support timely deterioration management.
Stated by East Lancashire Hospitals NHS Trust -
Action
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Stated by East Lancashire Hospitals NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Require paediatric triage documentation to confirm SBAR verbal handover and monitor compliance through monthly audit.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Review medical documentation and audit nursing records, providing feedback, education and support where required.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Assign the Tier 3 or above doctor to lead specialty and shift-change handovers for children’s care.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Review current intensive care-to-theatre transfer and handover practice.
Stated by University Hospitals Plymouth NHS Trust -
Action
Create a pre-operative handover checklist for complex intensive care patients, covering airway, allergies, medications, clotting, blood products and other relevant care information.
Stated by University Hospitals Plymouth NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.
Stated by University Hospitals Plymouth NHS Trust
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Position
Existing pre-operative assessment, intensive-care access and theatre briefing arrangements address relevant information-sharing needs, alongside a narrower new checklist.
Stated by University Hospitals Plymouth NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Develop and disseminate a urology referral form documenting transfer reasons, decisions, clinical priority, and coordination-centre notification.
Stated by University College London Hospitals NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.8
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Action
Complete and audit discharge-summary and safety-netting practice, and review existing discharge templates.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Complete and launch a new electronic discharge template, supported by local best-practice training.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Stated by Sheffield Health Partnership University NHS Foundation Trust
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Action
Include accurate, complete medical discharge-summary requirements in the medical staff rotation training programme.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Instruct inpatient Responsible Clinicians to record diagnoses in Insight for inclusion in discharge summaries.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Audit clinical record keeping, including risk assessments and discharge summaries.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Review the format and function of discharge summaries to include early warning signs of deterioration.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Incorporate the revised discharge-summary format into the new Rio electronic patient record system.
Stated by Sheffield Health Partnership University NHS Foundation Trust
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026