Recurring concern
Unreliable shift handover processes
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Request correctionFirst reported 21 Nov 2013•Latest report 26 Jun 2026
What this concern includes
Includes failures of shift-change handover processes, including incomplete handover content, failure to review or communicate relevant information, and premature destruction or unavailable handover records where this impairs reference by responsible staff.
Not included
- Excludes clinical handover failures between services or teams where no shift-change handover process is identified.
- Excludes generic record-retention deficiencies involving records unrelated to shift handover.
- Excludes failures of patient observations, care delivery or escalation where the shift-handover process is not itself deficient.
- Excludes generic communication or documentation deficiencies that are not specifically part of a shift-change handover.
- Reports
- 36
- Individual concerns
- 41
- Date range
- 2013–2026
- Stated actions
- 50
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 raised2
Failure to hand over important clinical information to the next shift
Failure to check patient records for up-to-date information at shift change
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
Introduce Safety Huddles at the start of ward and departmental shifts to discuss incidents, safety issues and enhanced observation needs.
Stated by Pennine Acute Hospitals NHS Trust -
Action
Launch and disseminate the Clinical Communication and Handover Policy with structured escalation and handover documentation.
Stated by Pennine Acute Hospitals NHS Trust -
Action
Conduct quarterly audits of compliance with the Clinical Communication and Handover Policy.
Stated by Pennine Acute Hospitals NHS Trust
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Concerns raised1
Failure to retain shift hand-over sheets
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.1
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Action
Consider introducing electronic archiving of ward and departmental handover sheets.
Stated by Tameside and Glossop Integrated Care 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
Paper handover sheets are not archived because confidentiality and maintaining reliance on the current sheet create practical constraints, although electronic archiving may be introduced.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to retain ward handover sheets for reference
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
Provide electronic handover access across Medicine Business Group wards, enabling retrospective access to patient handover information.
Stated by Stockport 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
Electronic handover records can be accessed retrospectively, so retaining shredded paper handover sheets is unnecessary and risks confidentiality and outdated information.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure to conduct effective shift handovers between nursing and medical staff
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
Develop standard operating procedures for information handover.
Stated by The Trust -
Action
Review handover efficiency at shift changes and incorporate identified improvements into the handover procedures.
Stated by The Trust
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Concerns raised1
Failure to conduct handovers by reference to nursing notes
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 formal paid handover time within staff shifts
This report raised 14 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
Alter shift patterns to create overlap for a protected, paid handover.
Stated by Your Health Limited
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Concerns raised1
Failure to provide full and effective shift handover
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 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
Introduce a shift-change handover process for sharing key information.
Stated by MERIDIAN HEALTHCARE LIMITED -
Action
Hold and document daily flash meetings to communicate significant changes and identify required activities and residents needing close monitoring.
Stated by MERIDIAN HEALTHCARE LIMITED
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Concerns raised2
Failure to review custody records and risk assessments at shift commencement
Incomplete handover of detainee health risks and observation requirements
This report raised 27 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
Document and standardise custody handover requirements, including transfer of risk-assessment information.
Stated by South Yorkshire Police -
Action
Regularly train current and new custody staff on the standardised handover process.
Stated by South Yorkshire Police
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
Existing custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.
Stated by South Yorkshire Police
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Concerns raised1
Lack of a written handover between evening and night supervisors
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
Failure of handover of responsibilities and tasks between day and night shifts
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.2
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Action
Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.
Stated by Barts Health NHS Trust -
Action
Send written and verbal instructions requiring junior doctors to record out-of-hours review needs on the trauma sheet before ending shifts.
Stated by Barts Health NHS Trust
Data last updated 7 September 2026