Recurring concern
Unreliable handover of care information and responsibility
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Request correctionFirst reported 17 Jan 2014•Latest report 26 Jun 2026
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
- Individual concerns
- 48
- Date range
- 2014–2026
- Stated actions
- 77
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 of handover documents to communicate required personal-care staffing arrangements
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 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
Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
Stated by Care UK -
Action
Review handover templates so they highlight key aspects of each resident’s care needs.
Stated by Care UK -
Action
Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
Stated by Care UK
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Concerns raised1
Failure of written handover records to capture vital information
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.2
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Action
Develop and roll out a standardised 24-hour handover template with daily and quarterly audits.
Stated by East London NHS Foundation Trust -
Action
Continue using Safety Huddles and document discussions on the handover template.
Stated by East London NHS Foundation Trust
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Concerns raised1
Lack of national guidance for healthcare handover to receiving prisons
This report raised 16 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
Other report recipients are responsible for addressing prison healthcare guidance, ACCT operations and family engagement because these concern day-to-day prison operations.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to clearly allocate responsibility for admission tasks during staff handover
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 raised1
Failure to provide continuity and handover between hospital and community psychology services
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.5
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Action
Provide formal handovers from inpatient psychologists to community psychological practitioners and coordinate follow-on care with community mental health teams.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Regularly audit handovers to verify safe transfer of psychological care to community teams.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review the operational model for transitions and handovers between inpatient and community psychological services.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Introduce locality-based joint inpatient-community consultations, formal pre-discharge handovers, and electronic recording of handover information.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Stated by Essex Partnership University 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
Patients do not always require immediate ongoing psychological therapy after discharge; treatment urgency should be determined by clinical need.
Stated by Essex Partnership University NHS Foundation Trust
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Position
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised3
Failure by outgoing care providers to contact incoming care providers and provide handovers about care needs and safety concerns
Failure by incoming care providers to identify previous care providers and seek a handover
Failure to provide handovers between care agencies about care needs and safety concerns
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.
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
Write to Herefordshire and Worcestershire CHC to seek clarification on handover protocols and establish best-practice standards for potential improvements.
Stated by Bluebird Care (Bromsgrove & Redditch) -
Action
Follow the enhanced handover process for all customers transitioning to or from Bluebird Care, not only CHC-funded customers.
Stated by Bluebird Care (Bromsgrove & Redditch) -
Action
Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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Action
Proactively seek opportunities to observe care calls when taking over packages, where circumstances require, to support assessment and handover.
Stated by Bluebird Care (Bromsgrove & Redditch)
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 existing CHC-mediated handover captured all relevant information, including sling concerns, so direct outgoing-to-incoming contact was not necessary in this case.
Stated by Bluebird Care (Bromsgrove & Redditch)
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Concerns raised2
Lack of clarity in formal handovers of Care Coordinator responsibility
Lack of a formal policy or procedure requiring recording of Care Coordinator handovers
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 and use a Trust-wide electronic Care Coordinator to Care Coordinator Transfer of Care Document for structured handovers and continuity oversight.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Attempt prompt recruitment and arrange at least two weeks’ overlap when a care coordinator gives notice, supporting effective handover and continuity of care.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to pass injury information on at handover or document its transfer
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.3
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Action
Strengthen staff communication by requiring documented concerns, daily records, written handovers, shift briefings and review of relevant resident records.
Stated by Sequoia CH Group Ltd -
Action
Require the Manager to review and sign off handover records daily for completeness and inclusion of key information.
Stated by Sequoia CH Group Ltd -
Action
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
Stated by Sequoia CH Group Ltd
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Concerns raised1
Failure to preserve handover 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 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
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
Stated by Exemplar Health Care
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
Electronic storage, printed copies and monthly checks ensure handovers cannot be overwritten and remain accessible.
Stated by Exemplar Health Care
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Position
Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Stated by Exemplar Health Care
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Concerns raised1
Failure to communicate healthcare waiting status during handover
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
Use daily residential roll books, guidance prompts and NOMIS records to capture healthcare requests, follow-up actions and relevant wellbeing information for staff sharing.
Stated by HM Prison and Probation Service
Data last updated 7 September 2026