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
Failure to hand over fall histories to returning care staff
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.4
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Action
Conduct a comprehensive review of the handover system.
Stated by Charing Dale Limited -
Action
Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.
Stated by Charing Dale Limited -
Action
Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
Stated by Charing Dale Limited
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Action
Introduce a specific audit of the handover process.
Stated by Charing Dale Limited
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
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Stated by Charing Dale Limited
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Concerns raised1
Failure to reliably convey and record vital information during handover to PICU
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.4
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Action
Use Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
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Action
Reinforce consultant-to-consultant handover requirements and record additional anaesthetic-PICU discussions in Epic.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
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Concerns raised3
Failure to document verbal first-responder handovers in patient records
Failure to ensure first-responder risk information is available to the assessing mental health team
Insufficient improvement of handover processes from first responders to Trust staff
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to provide detailed written clinical information and directions on discharge
Failure to provide explicit clinical direction and handover to night staff
This report raised 12 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 communicate pregnancy information effectively on hospital arrival
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.6
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Action
Review the crew’s learning from the EOC observation and confirm use of a structured information-sharing and handover approach.
Stated by London Ambulance Service NHS Trust -
Action
Develop a comprehensive cardiac-arrest handover procedure with tertiary centres to ensure key clinical information reaches receiving teams.
Stated by London Ambulance Service NHS Trust -
Action
Roll out the cardiac-arrest handover procedure and ATMIST AMBO tool to all receiving centres.
Stated by London Ambulance Service NHS Trust
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Action
Assess the feasibility of adding a handover audit mechanism to the developing electronic patient care record specification.
Stated by London Ambulance Service NHS Trust -
Action
Include SBAR handover training in the Emergency Department junior doctors' induction.
Stated by Whittington Health NHS Trust -
Action
Design SBAR handover into electronic clinical notes used from patient presentation through discharge.
Stated by Whittington Health NHS 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
The existing SBAR handover tool is considered sufficient to help crews convey relevant information to emergency departments, including in stressful circumstances.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Unavailability of an instantly transferable key-information patient document
This report raised 13 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
Implement the adapted Hospital Passport Transport Traffic Light System across West Sussex homes and the wider company.
Stated by Shaw Healthcare Limited
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Concerns raised1
Failure to record and communicate relevant presenting symptoms and prior clinical advice
This report raised 11 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
Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Stated by the Shrewsbury and Telford Hospital NHS 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
The Trust was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Concerns raised1
Failure of handovers to support effective communication and challenge
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.7
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Action
Operate a working group to standardise handovers through education and training, reporting to the Deteriorating Patient Steering Group.
Stated by Royal United Hospitals Bath NHS Foundation Trust -
Action
Review existing general medicine handover improvements to identify good practice for wider hospital adoption.
Stated by Royal United Hospitals Bath NHS Foundation Trust -
Action
Approve a draft standard operating procedure as the core standard for Trust handovers.
Stated by Royal United Hospitals Bath NHS Foundation Trust
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Action
Pilot further standardised paediatric handover improvements, including the validated ISOBAR tool.
Stated by Royal United Hospitals Bath NHS Foundation Trust -
Action
Launch an education and awareness campaign supporting SBAR as the core element of patient-level handovers.
Stated by Royal United Hospitals Bath NHS Foundation Trust -
Action
Allocate non-referred patients to an ED clinician expected to remain present throughout their ED stay, barring unforeseen circumstances.
Stated by Royal United Hospitals Bath NHS Foundation Trust -
Action
Incorporate SBAR into paediatric, nursing, and Observation Unit handover documentation and processes.
Stated by Royal United Hospitals Bath NHS Foundation Trust
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Concerns raised1
Failure to provide written handovers containing medication information during patient transfers
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.
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Concerns raised1
Poor provision of information on patient handover
This report raised 11 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
Deliver and audit the maternity quality improvement programme for safety briefings, handover and multidisciplinary assessment.
Stated by Cwm Taf Morgannwg University Local Health Board
Data last updated 7 September 2026