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 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.
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.4
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Action
Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.
Stated by Stockport NHS Foundation Trust -
Action
Remove all unauthorised patient handover documents from use.
Stated by Stockport NHS Foundation Trust -
Action
Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.
Stated by Stockport NHS Foundation Trust
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Action
Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.
Stated by Stockport NHS Foundation 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 Trust’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.
Stated by Stockport NHS Foundation Trust
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Position
The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.
Stated by Stockport NHS Foundation Trust
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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.
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
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.
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
Work with primary-care colleagues to improve the referral system.
Stated by Barts Health NHS Trust -
Action
Consider introducing a screened single referral telephone line with automatic acceptance of GP referrals.
Stated by Barts Health NHS Trust
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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.
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.4
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Action
Require cross-city transfers to include a written nursing handover document recording the patient’s falls risk.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Seek an agreement with Yorkshire Ambulance Service not to accept transfers without a handover document recording falls risk.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Trial a standalone electronic transfer document for cross-city transfers and work towards Trust-wide rollout.
Stated by Leeds Teaching Hospitals NHS Trust
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Action
Audit compliance with transfer-document use through a continuing rolling audit programme.
Stated by Leeds Teaching Hospitals NHS Trust
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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.
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 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.
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
Revise the referral protocol to require the leading specialty to document the agreed plan with the secondary specialty and identify who agreed it.
Stated by Bradford Teaching Hospitals NHS Foundation Trust
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
Plastic surgeons become involved after primary abscess management is complete, with the leading specialty documenting the agreed plan when plastics becomes involved.
Stated by Bradford Teaching Hospitals NHS Foundation Trust
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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.
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
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.
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
Integrate SBARD into every ward patient handover using a structured template completed by staff.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust -
Action
Deliver SBARD training through staff induction, clinical courses and ad hoc ward training.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust -
Action
Launch a NEWS2 e-learning course teaching SBARD.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
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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.
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
Revise SBAR handover teaching and use, incorporate practical scenarios into mandatory multidisciplinary training, update admission guidelines, and relaunch the tool.
Stated by St George'S University Hospitals NHS Foundation Trust
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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.
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