Recurring concern
Unreliable clinical handover processes
- Reports that mention this concern
- 67
- Times this concern has been raised
- 74
- Stated actions linked to this concern
- 107
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.
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.
Reports and published responses 67 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Lack of specific written confirmation of falls-risk handovers between wards
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Stockport 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.4
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Stockport NHS Foundation Trust
Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.
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Stockport NHS Foundation Trust
Remove all unauthorised patient handover documents from use.
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Stockport NHS Foundation Trust
Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.
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Stockport NHS Foundation Trust
Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.
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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Stockport NHS Foundation Trust
The Trust’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.
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Stockport NHS Foundation Trust
The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.
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Concerns raised1
Failure to flag deteriorating patients during handover
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring 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
Failure to provide effective referral communication and formal handover to the surgical team
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health 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
-
Barts Health NHS Trust
Work with primary-care colleagues to improve the referral system.
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Barts Health NHS Trust
Consider introducing a screened single referral telephone line with automatic acceptance of GP referrals.
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Concerns raised2
Failure to communicate identified falls risk to the receiving ward
Failure to provide written handover instructions or briefing notes during hospital transfer
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leeds Teaching 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.4
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Leeds Teaching Hospitals NHS Trust
Require cross-city transfers to include a written nursing handover document recording the patient’s falls risk.
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Leeds Teaching Hospitals NHS Trust
Seek an agreement with Yorkshire Ambulance Service not to accept transfers without a handover document recording falls risk.
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Leeds Teaching Hospitals NHS Trust
Trial a standalone electronic transfer document for cross-city transfers and work towards Trust-wide rollout.
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Leeds Teaching Hospitals NHS Trust
Audit compliance with transfer-document use through a continuing rolling audit programme.
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Concerns raised1
Failure of hospital discharge letters to communicate prophylactic anticoagulation requirements clearly
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Lack of timely and effective handover between surgical specialties
Absence of a formal handover protocol between surgical specialties
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Bradford Teaching 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
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Bradford Teaching Hospitals NHS Foundation Trust
Revise the referral protocol to require the leading specialty to document the agreed plan with the secondary specialty and identify who agreed it.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Bradford Teaching Hospitals NHS Foundation Trust
Plastic surgeons become involved after primary abscess management is complete, with the leading specialty documenting the agreed plan when plastics becomes involved.
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Concerns raised1
Failure to communicate significant risk information in handovers and MDTs
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to ensure effective communication and information handover between teams
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Norfolk and Norwich University 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.3
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Norfolk and Norwich University Hospitals NHS Foundation Trust
Integrate SBARD into every ward patient handover using a structured template completed by staff.
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Norfolk and Norwich University Hospitals NHS Foundation Trust
Deliver SBARD training through staff induction, clinical courses and ad hoc ward training.
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Norfolk and Norwich University Hospitals NHS Foundation Trust
Launch a NEWS2 e-learning course teaching SBARD.
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Concerns raised1
Failure to provide specific handover training and update the handover process
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- St George'S University 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
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St George'S University Hospitals NHS Foundation Trust
Revise SBAR handover teaching and use, incorporate practical scenarios into mandatory multidisciplinary training, update admission guidelines, and relaunch the tool.
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Concerns raised1
Failure to base staff handovers on clinical-record examination and update care plans for risk management
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo 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.
Data last updated 7 September 2026