First reported 17 Sep 2013•Latest report 24 Jun 2026
Definition
What this concern includes
Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
Not included
Ordinary shift handover with no transfer of the patient or care responsibility
Clinical treatment failures after a safe and complete transfer
Discharge to the community where no healthcare transfer process is involved
Reports
103
Distinct published reports
Individual concerns
131
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
151
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.
NHS England14
Department of Health and Social Care10
University Hospitals Sussex NHS Foundation Trust5
Betsi Cadwaladr University LHB4
HM Prison and Probation Service4
Manchester University NHS Foundation Trust4
Swansea Bay University Local Health Board4
University Hospitals of Derby and Burton NHS Foundation Trust4
Welsh Government4
Greater Manchester Mental Health NHS Foundation Trust3
Healthcare Inspectorate Wales3
Stockport NHS Foundation Trust3
Avon and Wiltshire Mental Health Partnership NHS Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust2
Bedfordshire Hospitals NHS Foundation Trust2
NHS trust66
Executive non-departmental public body15
Healthcare site13
Ministerial department11
Local health board10
Type not available7
Residential care home5
Devolved government4
Executive agency4
Health and care inspectorate3
Independent healthcare provider3
Prison or young offender institution3
Private limited company3
Company limited by guarantee2
Health and social care service regulator2
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.
Gwent
Concerns raised2
Delays in transferring patients between antenatal and HDU wards
Failure to identify causes of transfer delays and take steps to avoid unnecessary delay recurring
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Hampshire, Portsmouth and Southampton
Concerns raised2
Lack of clear escalation procedures during complex case transfers
Lack of senior management oversight of complex case transfers
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Lack of plan for transfer to a tertiary centre
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 concerns
Each 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
Action
Maintain recurring major-haemorrhage and emergency scenario training, including escalation, blood-supply, role-clarity, documentation and transfer exercises.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Use SBARD as a decision-support tool for escalation and transfer discussions.
Stated by Nuffield HealthStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Incorporate tertiary-referral criteria and senior clinician-to-ambulance communication into scenario-based training.
Stated by Nuffield HealthStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Calling emergency services was an appropriate response because transfer to an NHS facility providing Level 3 care would have been required.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The Regulation 28 concerns did not contribute to the patient’s death.
Stated by Nuffield HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to maintain a clear, effective and documented communication system for wound management care plans
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 concerns
Each 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
Action
Require documentation of all hospital and community-team calls, unsuccessful attempts and mitigation for missing treatment plans.
Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Record hospital admission and discharge-planning calls in Nourish with contact details, timing and required follow-up.
Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Require referrals to tissue-viability nurses or community teams within 24 hours, including photographs and current treatment-plan information.
Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Issue a Trust-wide alert requiring two Transfer of Care documentation copies for care-home discharges.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Audit five care-provider discharges per ward to verify Transfer of Care documentation is retained in patient records.
Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Action
Establish a task and finish group to improve discharge checklist quality and information.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Improve the quality and information included in the discharge checklist through the task and finish group.
Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 November 2025.
Avon
Concerns raised1
Lack of a system for passing important healthcare information between criminal justice healthcare providers during conveyance
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 concerns
Each 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
Continue discussions with PECS to commence pilots enabling Liaison and Diversion services to access and update the Digital Person Escort Record.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 October 2025.
Sunderland
Concerns raised1
Lack of clear procedures for medication management when a discharge letter cannot be located
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 concerns
Each 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
Action
Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
South Wales Central
Concerns raised1
Failure of safeguards for moving patients requiring critical care during times of pressure
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 concerns
Each 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
Action
Write to Cardiff and Vale University Health Board to confirm clinical governance and safe clinical cover for future critical-care-unit maintenance.
Stated by Welsh GovernmentStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Developed an Electrical Failure Emergency Action Card covering power-failure response, vulnerable-patient evacuation, emergency decanting and business-continuity arrangements.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Implemented a Critical Care Escalation Plan governing staffed bed capacity, patient prioritisation, delayed-transfer escalation, clinically led transfers and diversion arrangements.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Developed a Major Incident Plan framework defining emergency command, reporting, escalation, evacuation, triage, patient transfer, communications and critical-care staff responsibilities.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Conduct annual stress testing and live major-incident exercises at least every three years, maintaining training records.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Regularly review and simulate critical-care escalation and major-incident plans.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025.
Action
Provide ongoing staff training in major-incident response and escalation procedures.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Day-to-day operation and management of the hospital site and services remain the statutory responsibility of Cardiff and Vale University Health Board.
Stated by Welsh GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The existing estate was not the primary cause of the death, although estate improvements and resulting patient relocation contributed to it.
Stated by Welsh GovernmentDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Lack of clinical handover to receiving 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 concerns
Each 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
Action
Develop and implement a standard ED-to-EADU handover process and form that includes specialist requirements such as cardiac monitoring.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Audit the implemented ED Patient Handover Form monthly from September until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Introduce the ED patient handover process and form for transfers, including communication of cardiac monitoring and other specialist requirements.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Audit compliance with the ED patient handover form monthly after the scheduled September audit until consistent compliance is demonstrated.
Stated by James Paget University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Inner West London
Concerns raised1
Failure to ensure accurate and updated clinical information for referral acceptance and patient transfer
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 concerns
Each 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
Providers have limited recourse to pursue proceedings against medical professionals based in third countries.
Stated by Department of Health and Social CareUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Responding to the concern falls outside the respondent’s remit and is instead a matter for the Health Department.
Stated by Foreign, Commonwealth & Development OfficeOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Health Department should liaise with the referring country’s health team to determine whether travellers are fit to travel.
Stated by Foreign, Commonwealth & Development OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Failure to ensure receipt of all relevant patient-care information before transfer
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 concerns
Each 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
Action
Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
Stated by Highfield Care Home, WrexhamStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
Action
Review the care-home discharge plan form to define observation and medication frequencies clearly.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.
Action
Share the finalized and approved form changes with the North Wales Care Home Forum.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
Action
Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
Action
Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
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Includes failures in healthcare transfer procedures, coordination, responsibility, transfer documentation and provision of complete clinical information to the transporting or receiving team.
