Recurring concern
Unreliable shift handover processes
- Reports that mention this concern
- 36
- Times this concern has been raised
- 41
- Stated actions linked to this concern
- 50
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.
What is 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.
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 36 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to communicate patient status to incoming staff
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Devon Partnership 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.1
-
Devon Partnership NHS Trust
Use ward allocation boards, shift planners, staff identification boards and minimum handover standards to communicate patient allocations and status to incoming staff.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Devon Partnership NHS Trust
Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.
-
Concerns raised1
Lack of a reliable system for recording and reading important wing information and outstanding tasks during Senior Officer handover
This report raised 11 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.
-
Concerns raised1
Failure of handover to provide sufficient patient knowledge and review time
This report raised 6 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.
-
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
Inconsistent shift handover communication
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
Failure to provide 1:1 neonatal nurse/cotside handover at shift change
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026