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
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.
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 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.
Linked responses
- Royal College of Paediatrics and Child Health
- The 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
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The Trust
Conduct rolling audits of communication and documentation to identify compliance gaps and remedial measures.
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The Trust
Implement the commissioned improvement programme to embed reliable communication, handover and documentation processes in clinical practice.
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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Royal College of Paediatrics and Child Health
The NHS Trust, rather than the College, is responsible for responding on local communication, record keeping, policies and procedures.
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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.
Linked response
- Walsall Healthcare 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.1
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Walsall Healthcare NHS Trust
Formalise neonatal handover processes.
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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.
Linked response
- Manchester University 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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Manchester University NHS Foundation Trust
Implement and roll out a clinically revised Team Brief, including an Introductions Board, staff-presence checks, and reordered clinical discussion prompts.
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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.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Department of Health and Social Care
The Department considers the concerns matters for local comment and resolution rather than national action.
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Department of Health and Social Care
Specific concerns should be redirected to Fairfield General Hospital for consideration after North West Ambulance Service’s response.
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Department of Health and Social Care
Existing handover procedures should ensure triage staff access important patient information, so retaining paramedic notes is not required.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
Linked response
- University Hospitals Sussex 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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University Hospitals Sussex NHS Foundation Trust
Improve information quality and clinical handover when patients transfer from the Acute Medical Unit to specialist wards.
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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.
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 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.
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 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.
Linked response
- Tameside General Hospital
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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Tameside General Hospital
Review record-keeping training to reinforce communication, careful handover and avoidance of unclear abbreviations.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026