Recurring concern
Unreliable healthcare patient transfer processes
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Request correctionFirst reported 17 Sep 2013•Latest report 24 Jun 2026
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
- Individual concerns
- 131
- Date range
- 2013–2026
- Stated actions
- 151
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.
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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.
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.
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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.
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.3
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Action
Redesign, approve and barcode the SBAR patient-transfer handover tool.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Trial the amended escort-assessment guide and SBAR transfer tool in high-risk clinical areas.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Launch the adapted SBAR patient-transfer tool Trust-wide after pilot feedback and audit results.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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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.
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.1
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Position
The mobility information was consistent with documented needs, and suitable equipment was arranged before discharge.
Stated by Northern Care Alliance NHS Foundation Trust
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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.
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.
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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
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.2
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Position
A national minimum dataset exists for inter-provider hospital transfers, contrary to the concern that only electronic transfer information is required.
Stated by NHS England
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Position
Trusts or providers are responsible for robust handover and transfer procedures for inter-hospital transfers, rather than national policy.
Stated by NHS England
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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.
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.1
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Position
Existing cross-site bed-management, transfer and escalation arrangements are considered sufficient to minimise treatment delays.
Stated by University Hospitals of North Midlands NHS Trust
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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.
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.
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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
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
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Action
Implement and operate enhanced ward-to-ward transfer documentation requiring equipment readiness confirmation and explanations for unavailable equipment.
Stated by Hill Dickinson LLP
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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Position
Existing ward-transfer documentation and process changes are considered sufficient to address the identified recurrence risk, so no further Regulation 28 action is needed.
Stated by Hill Dickinson LLP
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Concerns raised1
Failure to provide adequate information during transfer of patients between GP practices
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.4
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Action
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.
Stated by NHS Surrey and Sussex Integrated Care Board -
Action
Clarify the digital issues causing corruption or loss of correspondence during GP-to-GP data transfer.
Stated by NHS Surrey and Sussex Integrated Care Board -
Action
Clarify the reasons for delayed paper-record transfers against Primary Care Support England’s contractual obligations.
Stated by NHS Surrey and Sussex Integrated Care Board
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Action
Have the Task and Finish group report on prescribing-safety and patient-transfer issues within six to eight weeks.
Stated by NHS Surrey and Sussex Integrated Care Board
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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Position
NHSE commissions Primary Care Support England, which is responsible for the paper-record transfer service.
Stated by NHS Surrey and Sussex Integrated Care Board
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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.
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
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Action
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
Data last updated 7 September 2026