First reported 17 Jan 2014•Latest report 26 Jun 2026
Definition
What this concern includes
Includes failures in the dedicated handover process for care information or responsibility, including absent or unclear procedures, incomplete or unauditable handover records, failure to transfer relevant information, and unclear or uncompleted handovers between care staff, managers, coordinators or successor services.
Not included
Excludes clinical handovers between healthcare professionals where the existing clinical-handover concern is the more specific supported boundary.
Excludes failures of discharge, inter-service transfer or general continuity processes where no care-handover deficiency is identified.
Excludes generic communication, staffing, documentation or training deficiencies unless they directly impair the transfer of care information or responsibility during handover.
Excludes non-care operational handovers, such as fire-and-rescue incident roles or general workplace shifts, unless the assertion concerns transfer of responsibility for care.
Reports
45
Distinct published reports
Individual concerns
48
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
77
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.
Department of Health and Social Care3
Care Quality Commission2
Essex Partnership University NHS Foundation Trust2
Herefordshire and Worcestershire Health and Care NHS Trust2
HM Prison and Probation Service2
National Institute for Health and Care Excellence2
Son of the deceased2
Sussex Partnership NHS Foundation Trust2
Worcestershire Acute Hospitals NHS Trust2
Arden Court1
Bank Close House1
Barts Health NHS Trust1
Bedford Prison1
Belle Green Court1
Betsi Cadwaladr University LHB1
NHS trust28
Private limited company6
Healthcare site4
Prison or young offender institution4
Type not available4
Domiciliary care provider3
Executive non-departmental public body3
Ministerial department3
Nursing home3
Executive agency2
Health and social care service regulator2
Independent healthcare provider2
Local health board2
Residential care home2
Community interest company1
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.
East Riding and Hull
Concerns raised1
Failure to provide handover information between care shifts
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.2
Action
Replace the paper diary with a structured handover process providing staff with shared resident information.
Stated by Westfield Residential HomeStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Action
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Stated by Care Quality CommissionNo action considered necessaryThe respondent said that no further action was needed.
Position
Inspection evidence identified no concerns with handover processes between staff.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to complete handovers between ACCT staff
This report raised 11 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.1
Position
Responsibility for the concerns about HMPPS and HMP Pentonville rests with separate organisations, so no response is proposed.
Stated by Practice Plus GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised1
Failure to provide complete current medication and stop-date information during care handover
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.
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
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete 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.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Dorset
Concerns raised1
Lack of written local guidance for undertaking and recording handovers
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.2
Action
Develop and take SBAR-based inpatient handover guidance through internal governance.
Stated by Dorset Healthcare University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Scope handover processes across all mental health inpatient units by June 2026 to identify required changes.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Detailed handover guidance for every healthcare facility would be impractical for a central organisation and unsuitable for differing local contexts.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
DHUFT is responsible for addressing the lack of written local handover guidance or policy.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Coventry
Concerns raised1
Failure to pass important risk information to the Home Treatment Team
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.2
Action
Revise the internal-transfer SOP to clarify handover dates, care-package ownership and joint handover meetings.
Stated by NHS Coventry and Warwickshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
Action
Audit internal transfers after SOP ratification to assess compliance and identify further improvement opportunities.
Stated by NHS Coventry and Warwickshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 21 January 2026.
Derby and Derbyshire
Concerns raised1
Failure to conduct formal handovers between shifts
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
Strengthen documentation requirements so verbal handover information is consistently and accurately recorded.
Stated by Bank Close HouseStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Bedfordshire and Luton
Concerns raised1
Failure to communicate relevant risk information through handovers and records
This report raised 6 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.1
Action
Strengthen shift handovers through clearer risk-information sharing expectations and allocated time for comprehensive handovers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
West Yorkshire Eastern
Concerns raised1
Lack of a formal system for communication, information sharing and handover between the respite facility and the Intensive Support Service
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.8
Action
Use a standardised daily handover template to capture clinical information, reviews, tasks, incidents, MDT comments and required follow-up.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Hold a daily Oasis–CRISS huddle to discuss handover information and address immediate actions and queries.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Ensure CRISS shift coordinators bring Oasis handover information to each locality’s daily multidisciplinary team meeting.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Record handover details and required actions in Oasis’s own system.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Add Oasis handover notes, MDT discussions and required actions to LYPFT care records.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Provide training on the handover sheet, including each organisation’s roles and responsibilities.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Monitor handover-process compliance and effectiveness through audits and feedback mechanisms.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Explore Oasis staff access to LYPFT’s electronic patient record and discuss the proposal through the operations meeting.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceStated 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.1
Position
Existing referral, admission, joint review, interface, operations and governance processes provide formal communication and risk-management arrangements.
Stated by Leeds and York Partnership NHS Foundation Trust and Leeds Survivor-Led Crisis ServiceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Failure to maintain adequate discharge handover information
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.2
Action
Operate a Trust-wide action group to improve discharge processes and report to the Patient Safety Review Group.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Operate a Trust-wide action group to drive discharge-process quality improvement and report to the Patient Safety Review Group.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Worcestershire
Concerns raised1
Absence of a formal, documented handover system between hospital and Neighbourhood Team
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.2
Action
Develop a handover form containing wound-care advice drawn from electronic patient-record and Tissue Viability records.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 February 2025.
Action
Send the wound-care handover form home with discharged patients for sharing with professionals providing care at home.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 February 2025.
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Includes failures in the dedicated handover process for care information or responsibility, including absent or unclear procedures, incomplete or unauditable handover records, failure to transfer relevant information, and unclear or uncompleted handovers between care staff, managers, coordinators or successor services.
