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 raised2
Lack of clear, detailed transfer documentation covering medication, medical history and recurrent falls
Failure to request a transfer document
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
Use standardized SBAR transfer documentation to communicate patients’ clinical history, needs and risks between care providers.
Stated by Derbyshire Community Health Services NHS Foundation Trust and University Hospitals of Derby and Burton NHS Foundation Trust
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
DCHS considers its established Admission, Discharge and Transfer Policy and SBAR process sufficient for safe patient transfers.
Stated by Derbyshire Community Health Services NHS Foundation Trust and University Hospitals of Derby and Burton NHS Foundation Trust
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Position
UHDB considers established transfer, admission-assessment and information-sharing processes sufficient to support safe information exchange between care providers.
Stated by Derbyshire Community Health Services NHS Foundation Trust and University Hospitals of Derby and Burton NHS Foundation Trust
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Concerns raised1
Lack of specific written confirmation of falls-risk handovers between 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 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
Relaunch the formal patient handover document across the Trust through weekly bulletin and targeted governance-team emails.
Stated by Stockport NHS Foundation Trust -
Action
Remove all unauthorised patient handover documents from use.
Stated by Stockport NHS Foundation Trust -
Action
Audit use of the correct patient handover document through the senior nursing team’s ward audit programme.
Stated by Stockport NHS Foundation Trust
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Action
Use the patient handover document in a Chief Nurse-led senior nurse walkround to reinforce communication of risks during transfers.
Stated by Stockport NHS Foundation Trust
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
The Trust’s formal handover document records falls risk for all transferred patients, contrary to the concern that no specific written confirmation is required.
Stated by Stockport NHS Foundation Trust
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Position
The six-hour assessment standard is retained because it allows admission and accurate documentation, while formal handover provides immediate risk communication.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Insufficient clarity about key contacts during inter-provider transfers between SASH and RSFT
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.
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.2
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Action
Implement an inter-organisation transfer pathway that gives patients, GPs and receiving clinicians the receiving organisation’s nominated contact details.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust -
Action
Ratify and use a proforma transfer letter, providing it to patients at their final face-to-face visit and copying it to their GP and receiving Clinical Nurse Specialist.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust
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Concerns raised1
Failure to consult PLS staff about escort and transfer arrangements
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 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 raised3
Lack of clear procedures for transferring patients under a section
Lack of clear procedures for documentation and resources accompanying transferred patients
Delays in accepting transfers of patients under a section
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
Distribute interim transfer guidance to staff of both Trusts.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation Trust -
Action
Amend inter-Trust agreements and relevant policies to clarify responsibilities for transferring detained patients.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation Trust -
Action
Develop a co-produced operational protocol defining safe transfer, referral, escalation, documentation, resources, multidisciplinary review and responsible clinicians.
Stated by Barnsley Hospital NHS Foundation Trust and South West Yorkshire Partnership Teaching NHS Foundation Trust
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Concerns raised1
Failure to provide a nurse escort during transfer of severely unwell and confused patients
This report raised 9 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.2
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Position
Cross-city nurse escorts are sometimes impracticable because they remove experienced staff for over an hour and may compromise care of other patients.
Stated by Leeds Teaching Hospitals NHS Trust
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Position
Yorkshire Ambulance Service facilitates safe transfer for cross-city patients instead of a Trust nurse escort.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Inadequate and incomplete transfer and communication from inpatient care to the CMHT
This report raised 9 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
Address coordination of diabetes management at discharge through the diabetes steering group.
Stated by Greater Manchester Mental Health 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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Position
Existing discharge CPA requirements in the CMHT procedure and clinical-record audits are relied upon to address discharge planning compliance.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Inadequate transfer and communication from inpatient care to the HBTT
This report raised 9 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
Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.
Stated by Greater Manchester Mental Health 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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Position
HBTT staff reviewed the patient before discharge and considered that the information needed to support transfer had been shared verbally.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to document justified falls-risk reassessments during hospital transfer
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 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
Place the AFLOAT assessment and observation chart into the NerveCentre electronic care record, with mandatory daily registered-nurse review.
Stated by Northumbria Healthcare NHS Foundation Trust
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Concerns raised1
Departure from established procedures for safe transfers from the emergency department to the observation unit
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 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
Run a weekly task-and-finish group and audits to improve discharge and transfer documentation compliance across both sites.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Data last updated 7 September 2026