Recurring concern
Unreliable healthcare patient transfer processes
- Reports that mention this concern
- 103
- Times this concern has been raised
- 131
- Stated actions linked to this concern
- 151
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.
What is 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
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 103 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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 commence a trial of new patient-transfer documentation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- the Queen Elizabeth Hospital, King'S Lynn, 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.3
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the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Redesign, approve and barcode the SBAR patient-transfer handover tool.
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the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Trial the amended escort-assessment guide and SBAR transfer tool in high-risk clinical areas.
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the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
Launch the adapted SBAR patient-transfer tool Trust-wide after pilot feedback and audit results.
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Concerns raised1
Failure to provide accurate mobility information during hospital-to-home communication
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Northern Care Alliance NHS Foundation 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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Northern Care Alliance NHS Foundation Trust
The mobility information was consistent with documented needs, and suitable equipment was arranged before discharge.
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Concerns raised1
Failure of the transfer solution to include weekend transfers
This report raised 5 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 raised2
Failure of the electronic transfer system to support recording and transmission of all information necessary for an effective handover
National transfer policy failing to require all information necessary for an effective handover
Linked response
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS England
A national minimum dataset exists for inter-provider hospital transfers, contrary to the concern that only electronic transfer information is required.
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NHS England
Trusts or providers are responsible for robust handover and transfer procedures for inter-hospital transfers, rather than national policy.
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Concerns raised1
Poor communication during transfers between County Hospital and Royal Stoke
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals of North Midlands NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University Hospitals of North Midlands NHS Trust
Existing cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.
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Concerns raised2
Failure to adhere to the Trust’s Transfer Policy
Lack of supporting paperwork for patient transfers
This report raised 5 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 raised2
Failure to ensure immediate availability and readiness for use of patient-owned medical equipment after internal transfers
Lack of a system to ensure that patient-owned medical equipment remains with patients during internal hospital transfers
Linked response
- Hill Dickinson LLP
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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Hill Dickinson LLP
Implement and operate enhanced ward-to-ward transfer documentation requiring equipment readiness confirmation and explanations for unavailable equipment.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Hill Dickinson LLP
Existing ward-transfer documentation and process changes are considered sufficient to address the identified recurrence risk, so no further Regulation 28 action is needed.
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Concerns raised1
Failure to provide adequate information during transfer of patients between GP practices
Linked response
- NHS Surrey and Sussex Integrated Care Board
Stated actions 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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NHS Surrey and Sussex Integrated Care Board
Alert local primary care to safe data transfer, robust coding and restricted medication quantities for high-risk patients, advising practices to adopt a blanket policy.
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NHS Surrey and Sussex Integrated Care Board
Clarify the digital issues causing corruption or loss of correspondence during GP-to-GP data transfer.
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NHS Surrey and Sussex Integrated Care Board
Clarify the reasons for delayed paper-record transfers against Primary Care Support England’s contractual obligations.
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NHS Surrey and Sussex Integrated Care Board
Have the Task and Finish group report on prescribing-safety and patient-transfer issues within six to eight weeks.
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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NHS Surrey and Sussex Integrated Care Board
NHSE commissions Primary Care Support England, which is responsible for the paper-record transfer service.
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Concerns raised3
Failure to provide clinical review before transfer
Failure to provide a clinical escort during transfer
Failure to protect the airway during transfer of a patient with severely reduced consciousness and vomiting risk
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- United Lincolnshire Teaching Hospitals 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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United Lincolnshire Teaching Hospitals NHS Trust
Commence a serious incident investigation to review the care provided.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026