Recurring concern

Unreliable clinical handover processes

First to latest report 27 Nov 2013 — 10 Jun 2026

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.

Reports and published responses 67 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Carmarthenshire and Pembrokeshire

    AI-generated summary

    Mr Page · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Page was admitted to hospital after a fall, underwent surgery, and later fell from his bed, fracturing his cervical spine; his condition deteriorated and he died on 2 May 2014. Concerns included the absence of a falls risk assessment and low bed, communication needs after handover, and the provision of sufficient nursing staff when greater staffing levels were required.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of training in communication following patient handover

    Wider context from the report

    “1. There was a training need identified regarding communication following patient handover. ”

    Source location

    Mr Page · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. South and West Cambridgeshire

    AI-generated summary

    Anne Elizabeth Sandever · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Anne Elizabeth Sandever, a diabetic woman with acute on chronic renal failure, was admitted to hospital on 3 February 2014, deteriorated after transfer to Walnut ward, and died on 6 February 2014. The concerns included gaps in nursing and medical observation, poor communication and handover about her diabetes, lack of intravenous fluids despite renal failure, and insufficient investigation of the incident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Poor communication and handover of patient information

    Wider context from the report

    “(2) Communication and handover was poor, no one on the ward knew Mrs Sandever was diabetic or took appropriate care of her diabetic control. ”

    Source location

    Anne Elizabeth Sandever · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement revised ward-transfer and SBAR requirements, including documented face-to-face handover, transfer risk assessment and nurse transfer for patients with MEWS of at least 3.

    Verbatim wording from the response

    “The recommendations coming from our internal investigation on this issue were that the ward transfer policy and the SBAR chart [which documents the key information at transfer] should be reviewed and updated and that this update would specifically include a requirement to ensure and document that a face to face handover has occurred at the point of transfer from one clinical area to another. All patient transfers would also be risk assessed and any patients who have a MEWS score of ≥3 will be transferred by a nurse who knows the patient.”

    Source location

    2014-0393-Response_Redacted
    Page 2 · response
    Published 4 September 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor revised transfer and handover arrangements through internal audit.

    Verbatim wording from the response

    “This work is already under way, with the revised policy implemented, and we have a target date of the end of December 2014 for all related actions to have been put in place. This will then be monitored for effectiveness via internal audit.”

    Source location

    2014-0393-Response_Redacted
    Page 2 · response
    Published 4 September 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Present the anonymised case and learning on safe handover and deteriorating-patient recognition at a Clinical Governance Day.

    Verbatim wording from the response

    “Finally, we have presented this case, in an anonymised form, as part of the lessons learned section of a Clinical Governance Day, to make more staff aware of the issues identified and, especially, the core learning around safe handover and the recognition of, and response to, deteriorating patients.”

    Source location

    2014-0393-Response_Redacted
    Page 3 · response
    Published 4 September 2014

    Open published response

  3. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thomas George Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incomplete handovers between primary and secondary care providers

    Wider context from the report

    “(1) No criticism is made of the actions of the Out of Hours Doctor ████████. The inquest however revealed the importance of full and accurate handover between primary and secondary care providers. Such handovers should record full observations and details of any medication already given (for instance painkillers may mask fever). Can the clinical director confirm OOH doctors observe this practice. ”

    Source location

    Thomas George Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Rainer Wickens · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Rainer Wickens fell through the roof of a single-storey rear extension while assisting with its demolition, sustaining a thoracic spine fracture. After surgery, concerns arose about low oxygen saturations and possible pulmonary embolism; he suffered a cardiac arrest and died before testing could be completed. The report identifies concerns about delayed treatment for clot formation, gaps in medical notes, poor handover communication, and delays in obtaining a CTPA scan.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Poor verbal communication at handovers between treating doctors

    Wider context from the report

    “Poor verbal communication at handovers between treating doctors ”

    Source location

    Rainer Wickens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Plymouth, Torbay & South Devon

    AI-generated summary

    Karen Lesley Peters · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Karen Peters suffered a fall and head injury in hospital on 28 March 2013, subsequently developing an acute subdural haemorrhage and dying on 29 March 2013 after delays in transfer to neurosurgical care. Concerns included nursing staffing and agency staff deployment, handover quality, neurological observations and escalation, administration of contraindicated anticoagulation, availability of airway support, and delays and coordination issues affecting time-critical transfer.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of nursing handovers to convey complete and accurate clinical information

    Wider context from the report

    “3. The quality of handover information I heard from two nurses, Nurse A and Nurse P. There was a clear conflict in their respective evidence as to what information was conveyed between them at handover. In particular, there was conflict as to whether Nurse A was advised of Karen’s earlier fall and the need for hourly neurological observations. ████████ explained at Inquest that he had now directed that all nursing handovers must be undertaken by reference to the Nursing Record. One of my concerns arising out of this was that there was no entry in the Nursing record advising of the need for the patient to undergo a CT Scan if there was a drop in recorded levels of consciousness. That note was only to be found in the medical records and neither Nurse A nor Nurse P considered these. ████████ explained to me that there will be an ongoing audit in relation to the quality and accuracy of nursing handovers. I would be pleased to learn from you the outcome of that audit. ”

    Source location

    Karen Lesley Peters · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. Manchester City

    AI-generated summary

    STEPHANIE DANIELS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of nurse review of recent records during admission or transfer handover

    Wider context from the report

    “2. Handover All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective. ”

    Source location

    STEPHANIE DANIELS · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out weekly checks of compliance with handover documentation requirements.

    Verbatim wording from the response

    “As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Instruct registered nurses to review recent admission records and risk information for unfamiliar patients, with understanding checked through supervision.

    Verbatim wording from the response

    “As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

    Verbatim wording from the response

    “As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

    Source location

    2013-0353-Response-by-Department-of-Health
    Page 1 · response
    Published 13 December 2013

    Open published response

  7. Berkshire

    AI-generated summary

    Edna Elsie Mary Eden · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Edna Elsie Mary Eden, who had been living independently, was admitted to hospital after feeling unwell and reporting recent right-sided chest pain. She remained in A&E and the AMU for approximately fourteen and a half hours before being seen by a doctor, then arrested and could not be revived. The report identified missed opportunities involving delayed medical review, failure to recognise or escalate abnormal findings, inadequate communication, incorrect observation scoring, and lack of antibiotic cover.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient information in clinical handovers

    Wider context from the report

    “(4) Clinicians were taking decisions over priority of seeing patients based only on a very vague description of Mrs Eden’s condition. Information at handovers appeared very limited. ”

    Source location

    Edna Elsie Mary Eden · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Strengthen use of the SBAR communication tool when notifying doctors about patients requiring review.

    Verbatim wording from the response

    “In addition TPP 231 has strengthened the use of Situation Background Assessment Recommendation (SBAR) tool. This is a communication tool used when notifying Doctors over the phone or in person of a patient for review. The tool ensures important information is conveyed in order to allow the Doctor to paint a picture of the patient’s condition and prioritise review as necessary.”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Establish a 24-hour Central Hub with patient tracking, referral and bleep management, workload oversight, handover, task allocation, escalation and senior-manager staffing.

    Verbatim wording from the response

    “The Trust has plans to introduce a 24 hours a day Central Hub system and the timescales for actions are stated in the enclosed action plan. It is envisaged the Hub will be located at Wexham Park Hospital and be equipped with IT systems and run by senior managers who will be responsible for ensuring the following:”

    Source location

    2013-0317-Response-by-Heatherwood-Wexham-Park-Hospital-NHS-Trust
    Page 2 · response
    Published 22 February 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026