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
Lack of procedures for care handovers
This report raised 20 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
A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.
Stated by Stars Social Support Limited
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Concerns raised1
Failure to leave information recording the admission decision and paramedic advice
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.1
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Action
Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Concerns raised1
Lack of practitioner cover and formal handover arrangements for Lead Practitioner caseloads during leave
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.1
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Action
Incorporate leave handover arrangements, particularly for vulnerable patients, into staff risk assessment training.
Stated by Sussex Partnership 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
The team-wide duty system is considered safer and sufficient than assigning leave cover to one individual practitioner.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to hand over fall histories to returning care staff
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.4
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Action
Conduct a comprehensive review of the handover system.
Stated by Charing Dale Limited -
Action
Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.
Stated by Charing Dale Limited -
Action
Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.
Stated by Charing Dale Limited
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Action
Introduce a specific audit of the handover process.
Stated by Charing Dale Limited
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 errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Stated by Charing Dale Limited
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Concerns raised1
Failure to reliably convey and record vital information during handover to PICU
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
Use Epic to record MDT outcomes and link clinician messages directly to patient records for cross-department information sharing.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Implement the spinal surgery ECMO pathway, including Joint Cardiac Conference review, postoperative location and consent planning, capacity checks, Epic documentation and multidisciplinary handovers.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust -
Action
Develop, test and launch a standardised electronic anaesthetic-to-ICU handover document with accompanying training.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
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Action
Reinforce consultant-to-consultant handover requirements and record additional anaesthetic-PICU discussions in Epic.
Stated by Great Ormond Street Hospital for Children NHS Foundation Trust
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Concerns raised1
Failure to communicate required increased observations during shift handover
This report raised 13 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
Implement and review the corporate shift-handover process, including documented handovers, incoming checks, staff allocation and accessible records.
Stated by Shaw Healthcare Limited
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Concerns raised1
Failure to hand over care
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.
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
A handover communication was documented, with an explicit discharge plan including consideration of palliative registration and ongoing care.
Stated by Northern Care Alliance NHS Foundation Trust
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Concerns raised1
Inadequate handover of mental health care information
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.
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 assign handover responsibility to a registered nurse
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 raised1
Inadequate quality and extent of handover instructions to agency staff
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.1
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Action
Provide agency staff with robust handovers and clear resident-care guidelines when their use is necessary.
Stated by BIOcareM
Data last updated 7 September 2026