Recurring concern
Unreliable clinical handover processes
Pin
Get email alerts
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.
-
Concerns raised1
Failure of the three-tier system to transfer key patient information quickly
This report raised 9 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.
-
Concerns raised1
Inadequate clinical communication and handover
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.2
-
Action
Conduct rolling audits of communication and documentation to identify compliance gaps and remedial measures.
Stated by The Trust -
Action
Implement the commissioned improvement programme to embed reliable communication, handover and documentation processes in clinical practice.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The NHS Trust, rather than the College, is responsible for responding on local communication, record keeping, policies and procedures.
Stated by Royal College of Paediatrics and Child Health
-
Concerns raised1
Inadequate handover for the arrival of a premature baby
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.1
-
Action
Formalise neonatal handover processes.
Stated by Walsall Healthcare NHS Trust
-
Concerns raised1
Failure to hand over known or suspected difficult airway information to paediatric anaesthetists
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.1
-
Action
Implement and roll out a clinically revised Team Brief, including an Introductions Board, staff-presence checks, and reordered clinical discussion prompts.
Stated by Manchester University NHS Foundation Trust
-
Concerns raised1
Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Position
The Department considers the concerns matters for local comment and resolution rather than national action.
Stated by Department of Health and Social Care
-
Position
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
Stated by Department of Health and Social Care -
Position
Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
Stated by Department of Health and Social Care
-
Concerns raised1
Failure to hand over patients’ continuing oxygen requirements during transfers between hospital departments
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.
-
Concerns raised1
Incomplete and ineffective clinical handover
This report raised 24 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
-
Action
Improve information quality and clinical handover when patients transfer from the Acute Medical Unit to specialist wards.
Stated by University Hospitals Sussex NHS Foundation Trust
-
Concerns raised1
Lack of transfer handover information about high falls risk
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to communicate and review relevant clinical information before risk decisions
This report raised 7 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.
-
Concerns raised1
Failure to hand over patient information between 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.
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
-
Action
Review record-keeping training to reinforce communication, careful handover and avoidance of unclear abbreviations.
Stated by Tameside General Hospital
Data last updated 7 September 2026