Recurring concern
Unreliable handover of care information and responsibility
- Reports that mention this concern
- 45
- Times this concern has been raised
- 48
- Stated actions linked to this concern
- 77
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.
What is 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.
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 45 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Failure to hand over outstanding investigations and required result checks during staff shift changes
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Plymouth 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.3
-
University Hospitals Plymouth NHS Trust
Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
-
University Hospitals Plymouth NHS Trust
Require review of outstanding tests and verbal and written handover before transferring MAU patients to wards.
-
University Hospitals Plymouth NHS Trust
Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
-
Concerns raised1
Lack of formal handover and transfer of important information between community nursing teams
Linked response
- Kent Community Health 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.4
-
Kent Community Health NHS Foundation Trust
Implement a formal process for transferring care between community nursing teams.
-
Kent Community Health NHS Foundation Trust
Revise transfer-of-care policies and procedures through an established working group.
-
Kent Community Health NHS Foundation Trust
Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.
-
Kent Community Health NHS Foundation Trust
Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.
-
Concerns raised1
Failure to hand over relevant patient and suicide-risk information to the leave escort
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership 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.1
-
Sussex Partnership NHS Foundation Trust
Ensure proper handovers with agency nurses accompanying patients.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Sussex Partnership NHS Foundation Trust
The shortcomings identified were unlikely to have prevented the tragic outcome.
-
Concerns raised1
Poor-quality staff handovers
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Partnerships in Care Group Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Partnerships in Care Group Limited
Review and standardise handover procedures using signed formal handover documents with a physical-health section.
-
Partnerships in Care Group Limited
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Partnerships in Care Group Limited
The handover concern did not apply on the relevant shift because staff attended handover and the late-arriving worker received a separate handover.
-
Concerns raised1
Lack of formal handover when primary care responsibility changed
This report raised 3 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026