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
Lack of a clear agreed policy or procedure for transferring patients with gastrointestinal bleeding
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.4
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Action
Develop an Upper GI Bleed Transfer Policy for Bassetlaw Hospital patients requiring transfer to Doncaster.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Make Bassetlaw staff aware of the specific Upper GI Bleed Transfer Policy through the Clinical Site Manager and Matron.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Submit the Upper GI Bleed Transfer Policy for ratification by the Patient Safety Review Group to support wider Trust dissemination.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Action
Monitor implementation of the Upper GI Bleed Transfer Policy through the Emergency Care Group Clinical Governance Team and Datix incident system.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Delays in accepting transfer of suspected aortic dissection patients while awaiting CT imagery
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.2
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Action
Clarify and reinforce to cardiothoracic registrars that aortic dissection referrals must be discussed immediately with the duty consultant, who decides transfer and any pre-transfer CT review.
Stated by Guy'S and St Thomas' NHS Foundation Trust -
Action
Extend the open-door policy to ascending-aorta and arch dissections, enabling consultant-authorised immediate transfer with guaranteed theatre and critical-care capacity.
Stated by Guy'S and St Thomas' 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
Clarified consultant escalation and guaranteed immediate transfer arrangements are considered sufficient to prevent recurrence of confusion and delay.
Stated by Guy'S and St Thomas' NHS Foundation Trust
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Concerns raised1
Failure of communication during inter-hospital 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.
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
Refresh and reaffirm emergency patient receiving and first-line management processes, including a ring-fenced spinal emergency bed and HDU escalation route.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust -
Action
Refresh and simplify proforma-based documentation for nursing and medical multidisciplinary teams.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust
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Concerns raised1
Failure to identify and transfer key clinical information to receiving teams
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.3
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Action
Revise and publish the inter-provider transfer Standard Operating Procedure for cancer pathway handovers.
Stated by Mid Yorkshire Teaching NHS Trust -
Action
Distribute further promotion of electronic systems and processes for transferring imaging and clinical data through local multidisciplinary teams.
Stated by Mid Yorkshire Teaching NHS Trust -
Action
Recirculate the updated pathway and highlight the need to complete referral forms fully and accurately.
Stated by Leeds Teaching Hospitals NHS 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
The lack of clinical details did not influence the final diagnosis, treatment or outcome.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised3
Failure to provide the Transfer of Care Form to escorting police for immediate availability to the custody nurse
Failure to ensure completion of the Transfer of Care Form by the examining doctor
Delays in completing the Transfer of Care Form at the time of examination
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.
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 hand over patients’ continuing oxygen requirements during transfers between hospital departments
Failure to provide required oxygen during patient transfers within a ward
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.
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 follow and document ward transfer procedures
This report raised 18 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
Educate ward nurses on patient moves, site-manager information requirements and transfer documentation.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Discuss avoiding late-night patient moves with clinical site managers responsible for bed allocation.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to communicate and acknowledge transfers of patient care between agencies
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.1
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Action
Communicate and record clear responsibility statements for all inter-agency care transfers across daytime and out-of-hours services, including on RiO and CareFirst.
Stated by Approved Mental Health Professional/Social Work Service
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Concerns raised1
Failure to use the required trolley for patient transfer
This report raised 24 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
Lack of transfer handover information about high falls risk
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026