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 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.
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
Use ward patient plans and boards to track investigations, tests and urgent treatment, with daily nursing and medical review.
Stated by University Hospitals Plymouth NHS Trust -
Action
Require review of outstanding tests and verbal and written handover before transferring MAU patients to wards.
Stated by University Hospitals Plymouth NHS Trust -
Action
Conduct formal handovers for every on-call team to transfer information and identify outstanding tests and concerns.
Stated by University Hospitals Plymouth NHS Trust
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Concerns raised1
Lack of formal handover and transfer of important information between community nursing teams
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
Implement a formal process for transferring care between community nursing teams.
Stated by Kent Community Health NHS Foundation Trust -
Action
Revise transfer-of-care policies and procedures through an established working group.
Stated by Kent Community Health NHS Foundation Trust -
Action
Improve transfer documentation so patients receive holistic reassessment and clearly documented care needs before transfer.
Stated by Kent Community Health NHS Foundation Trust
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Action
Monitor transfer-of-care arrangements through clinical audit and Trust committee structures.
Stated by Kent Community Health NHS Foundation Trust
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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.
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
Ensure proper handovers with agency nurses accompanying patients.
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 shortcomings identified were unlikely to have prevented the tragic outcome.
Stated by Sussex Partnership NHS Foundation Trust
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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.
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
Review and standardise handover procedures using signed formal handover documents with a physical-health section.
Stated by Partnerships in Care Group Limited -
Action
Review, revise and reissue the observation policy, brief relevant staff, obtain responsibility acknowledgements, and audit implementation with spot checks.
Stated by Partnerships in Care Group 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 handover concern did not apply on the relevant shift because staff attended handover and the late-arriving worker received a separate handover.
Stated by Partnerships in Care Group Limited
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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.
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