Recurring concern

Unreliable shift handover processes

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First reported 21 Nov 2013•Latest report 26 Jun 2026

Definition

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

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

HM Prison and Probation Service4

Care Quality Commission2

Department of Health and Social Care2

Ministry of Justice2

National Institute for Health and Care Excellence2

Pennine Acute Hospitals NHS Trust2

Alternative Futures Group Limited1

Barts Health NHS Trust1

Bedford Prison1

Betsi Cadwaladr University LHB1

Birmingham and Solihull Mental Health NHS Foundation Trust1

Bolton NHS Foundation Trust1

Care UK Limited1

Central and North West London NHS Foundation Trust1

Devon Partnership NHS Trust1

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.

25 Mar2021
Birmingham and Solihull
Concerns raised1
1. Failure to communicate significant risk information in handovers and MDTs
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Azra Parveen HUSSAIN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate significant risk information in handovers and MDTs
Wider context from the report
“1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”
Source location
Azra Parveen HUSSAIN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Dec2019
Manchester City
Concerns raised1
1. Failure to maintain auditable cross-shift handover of relevant information
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Tomasz Nowosad · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Tomasz Nowosad was found hanging by a ligature in an ordinary, non-safe cell at HMP Manchester on 2 February 2017, shortly after being transferred from the healthcare centre. The report identifies concerns about risk assessment, including reliance on his denials of suicidal thoughts, incomplete and delayed clinical records, inconsistent use of interpretation services, and his transfer to an ordinary wing despite expressed fears and mental health risks. The inquest jury concluded that the death was suicide contributed to by neglect.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to maintain auditable cross-shift handover of relevant information
Wider context from the report
“5 11 It is suggested that there should be an auditable process of ensuring that all appropriate information is handed over between different shifts of GMMH and HMPS staff so that there is a continuity and consistency of available information ”
Source location
Tomasz Nowosad · Prevention of Future Deaths report
Page 7 · concerns
Open source report
10 Dec2019
Brighton and Hove
Concerns raised1
1. Inadequate shift handovers
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Bethany Tengquist · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Bethany Tengquist hanged herself on 29 December 2018 after two telephone charging cables had been removed from her room but her dressing gown cord remained available. The report raises concerns that room checks and the removal of dangerous items were incomplete and flawed, and that staff may not have been properly trained.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate shift handovers
Wider context from the report
“2. Staff training and auditing. The evidence regarding the wholly inadequate completion of the handover and the accompanying documents in this case is of serious concern, again as reflected by the jury’s conclusion. The handover from late to night shift was chaotic and confused at best. The paperwork was in large parts either wholly inadequately completed or simply not completed at all. All of the agency and bank staff were either new, or at best, had only had a few shifts on Caburn. This clearly elevates the critical importance of a detailed, thorough and professional handover together with full and far more professional completion of the accompanying documentation. I specifically require identification of the steps proposed to dramatically improve these matters. ”
Source location
Bethany Tengquist · Prevention of Future Deaths report
Page 5 · concerns
Open source report
20 Nov2019
Manchester North
Concerns raised1
1. Failure to update handover information about expected welfare checks
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Gary Leyland · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Gary Leyland was found deceased in his supported accommodation on 13 November 2019 after taking excessive prescribed medication, with the inquest conclusion recording suicide and morphine toxicity. Concerns included failures to contact medical or mental health services after suicidal thoughts were disclosed, poor documentation and handover information, the use of security staff for welfare checks without clear evidence of training, and the absence of an updated risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to update handover information about expected welfare checks
Wider context from the report
“2. Only the handover sheets for the 7th and 8th November were updated to advise staff to “keep an eye” on Mr Leyland. NO updates were on the handover sheets for the 9-12th November despite the evidence being welfare checks would still have been expected on these dates. It is therefore unclear how security staff working the 10th and 11th November (weekend) would have been able to expect to check on Mr Leyland. ”
Source location
Mr Gary Leyland · Prevention of Future Deaths report
Page 2 · concerns
Open source report
28 Aug2019
London (West)
Concerns raised1
1. Failure to provide explicit clinical direction and handover to night staff
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Amir Siman-Tov · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Amir Siman-Tov died at Colnbrook Immigration Removal Centre on 17 February 2016 after taking an overdose of codeine. The concerns included inconsistent involvement of healthcare staff in the ACDT self-harm reduction process, inconsistent medication checks, inadequate hospital discharge information and handover, insufficient monitoring after his return, and shortcomings in the emergency response.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide explicit clinical direction and handover to night staff
Wider context from the report
“10. Mr Siman-Tov’s care was then handed over to night staff. No explicit direction or handover was given. The explanation for this was that the observations should be second signature and did not need elaboration. ”
Source location
Amir Siman-Tov · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Jun2019
West Sussex
Concerns raised2
1. Inadequate shift handover documentation for highlighting concerns and increased observations
2. Failure to communicate required increased observations during shift handover
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement and review the corporate shift-handover process, including documented handovers, incoming checks, staff allocation and accessible records.
  Stated by Shaw Healthcare LimitedStated completed
AI-generated summary

James William Francis · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

James William Francis, who had a history of falls and balance difficulties, suffered an unwitnessed fall at his care home on 9 April 2017 and later developed repeated vomiting and deterioration. He was admitted to hospital with a large subdural haematoma and died on 11 April 2017. The principal concerns included failures in shift handover and monitoring, delays in seeking medical advice, inadequate information provided to paramedics, the patient’s positioning, staff training, and whether relevant guidelines sufficiently addressed this type of injury in elderly patients.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate shift handover documentation for highlighting concerns and increased observations
Wider context from the report
“I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day. However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations ”
Source location
James William Francis · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate required increased observations during shift handover
Wider context from the report
“I heard evidence from several staff members at different grades including two support workers responsible for Mr Francis’s daily care, a senior support worker and a team leader that they were unaware of Mr Francis recent fall or the fact that 30 minute observations needed to be carried out. In particular, both key support workers who knew Mr Francis best failed to carry out the 30 minute observations during the morning and afternoon shifts and on balance of probabilities it was likely that neither support worker was told either during the handover meeting or by the senior staff on duty that this was a requirement that day. However, it certainly seems that both support workers observed Mr Francis on a regular basis throughout the day and took appropriate action to report his condition and any change to senior staff. In another patient, this lack of handing on of vital information to key members of staff could be crucial I was shown a shift handover form but this is basic and contains no additional guidance or method to highlight particular concerns or need for increased observations ”
Source location
James William Francis · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and review the corporate shift-handover process, including documented handovers, incoming checks, staff allocation and accessible records.

Verbatim wording from the response
“Prior to your inquest we had already recognised a need to improve our handover arrangements at Deerswood and in March 2018 we had set up the attached “Shift Handover Form”.”

Source location
2019-0202-Response-by-Shaw-Healthcare
Page 2 · response
Published 23 August 2019
Open published response
21 May2018
Avon
Concerns raised1
1. Failure to review shift records 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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Michalla Jane SWEETING · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michalla Jane Sweeting was a remand prisoner undergoing detoxification who was found unresponsive in her cell at 07.00hrs on 2nd June 2016. The medical cause of death was aspiration of gastric content in association with methadone toxicity. Concerns included inadequate response to reported over-sedation, unsatisfactory handover between shifts, inadequate clinical observations, and failures in communication and assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to review shift records during handover
Wider context from the report
“1. Handover: a. That the handover includes all prisoners/patients undergoing detoxification. b. That the handover is the responsibility of the registered nurse c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths ”
Source location
Michalla Jane SWEETING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Oct2017
Worcestershire
Concerns raised3
1. Failure to assign responsibility for complete and thorough handover
2. Inadequate highlighting of particular patients' needs during handover
3. Inconsistent handover processes failing to ensure adequate information sharing
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use a standardized SBAR structure for clinical handovers across the hospital.
  Stated by Worcestershire Acute Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  The existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.
  Stated by Worcestershire Acute Hospitals NHS TrustExisting arrangements considered sufficient
AI-generated summary

Michael Edward Giles · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Michael Edward Giles became unwell, was admitted to hospital, underwent a diagnostic surgical procedure, then deteriorated and died. The report identified concerns about inconsistent shift handovers, lack of senior review at weekends, inadequate clinical and nursing leadership during a crisis, and inadequate case notes and medical records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to assign responsibility for complete and thorough handover
Wider context from the report
“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”
Source location
Michael Edward Giles · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate highlighting of particular patients' needs during handover
Wider context from the report
“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”
Source location
Michael Edward Giles · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent handover processes failing to ensure adequate information sharing
Wider context from the report
“(1) The handover process between shifts was expressed to be different throughout the hospital on different wards. This potentially leads to inconsistency with inadequate information being shared. It was not clear whose responsibility it was to ensure that the handover was undertaken in full and thorough fashion. The highlighting of the needs of particular patients who were the subject of the handover was inadequate. ”
Source location
Michael Edward Giles · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use a standardized SBAR structure for clinical handovers across the hospital.

Verbatim wording from the response
“1. You’ve invited the Trust to consider standardising the handover process across the hospital and to put in place a protocol whereby the identity of the person responsible for ensuring the handover takes place is clearly recognised.”

Source location
2017-0309-Response
Page 1 · response
Published 28 November 2017
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The existing SBAR handover structure and ward board rounds are considered robust arrangements for transferring clinical information.

Verbatim wording from the response
“The events surrounding this tragic case and your regulation 28 letter was discussed with the trainees in early November 2017. The conclusion from the trainees was that they were confident that the processes now in place were robust and they had not experienced any near misses as a consequence of inadequate handover. There is a standardised structure for handover which follows SBAR. This is an acronym for Situation, Background, Assessment, Recommendation. With reference to identifying a responsible person is a little more fraught. Handover takes place at multiple levels whilst the patient remains an inpatient.”

Source location
2017-0309-Response
Page 1 · response
Published 28 November 2017
Open published response
4 Apr2017
Buckinghamshire
Concerns raised1
1. Lack of review of wing log handover procedures
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

ARTHUR ALBERT MORLEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Arthur Albert Morley was a prisoner serving an indeterminate sentence at HMP Grendon when he was found hanging from a pipe in a sanitation area shortly after being told he would be returned to his previous prison. The report raised concerns about accessible ligature points, inadequate sanitation-room security and inspection arrangements, delays in reviewing procedures and incident learning, and insufficient communication and healthcare involvement in return-to-unit decisions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of review of wing log handover procedures
Wider context from the report
“(6) There has been no specific review of verbal and written wing log handover procedures between day and night wing staff with a view to better highlighting and acknowledging key events (such as an RTU decision) relevant to a prisoner on that particular wing. ”
Source location
ARTHUR ALBERT MORLEY · Prevention of Future Deaths report
Page 1 · concerns
Open source report
30 Jun2016
Warwickshire
Concerns raised1
1. Lack of formalised handover procedures between controllers coming on and off shift
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Strengthen controller handover training and incorporate handover requirements into the controller task book.
  Stated by Warwickshire PoliceStated completed
Respondent positions 1
1. Position
  The varied nature of OCC calls prevents handover procedures from being made over-prescriptive.
  Stated by Warwickshire PoliceUnable to act
AI-generated summary

Luisa Mendes · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Luisa Mendes was pronounced deceased on 25 October 2012 after a catastrophic abdominal bleed caused by rupture of the spleen, following the deliberate application of force by a third party. The report raised concerns about incident categorisation, handover procedures between control-room staff, and the STORM computer system's handling of unauthorised deferrals. The inquest also identified errors or omissions involving the police response, handover process, deferral of the response, computer-screen configuration, and supervision of the control room.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of formalised handover procedures between controllers coming on and off shift
Wider context from the report
“(2) The handover procedures between controllers coming on and off shift in the Operations and Communications Centre. The basis for the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift. ”
Source location
Luisa Mendes · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen controller handover training and incorporate handover requirements into the controller task book.

Verbatim wording from the response
“Compelling evidence was identified during the preparation and ultimate delivery of the evidence to the inquest that showed the handover procedure between controllers in the OCC required improvement. However, the complex and varied nature of the calls received within the OCC means that the handover process must be dynamic and cannot be subject of an over-prescriptive process. It has been recognised that there was a need to reinforce the critical importance of passing vital information between controllers. In order to achieve this, changes have been made to the initial training programme for controllers and additional requirements incorporated into the controller ‘task book’, which is a list of skills that controllers need to demonstrate before progression in their role.”

Source location
2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The varied nature of OCC calls prevents handover procedures from being made over-prescriptive.

Verbatim wording from the response
“2. The handover procedures between controllers coming on and off shift in the Operations and Communications Centre (OCC). The basis of the concern is that there are no formalised procedures and no specific training in relation to handovers between controllers coming on and off shift.”

Source location
2016-0243-Response-by-Warwickshire-Police
Page 3 · response
Published 30 June 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to communicate significant risk information in handovers and MDTs

Concerns raised1

Failure to maintain auditable cross-shift handover of relevant information

Concerns raised1

Inadequate shift handovers

Concerns raised1

Failure to update handover information about expected welfare checks

Concerns raised1

Failure to provide explicit clinical direction and handover to night staff

Concerns raised2

Inadequate shift handover documentation for highlighting concerns and increased observations

Failure to communicate required increased observations during shift handover

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

Concerns raised1

Failure to review shift records during handover

Concerns raised3

Failure to assign responsibility for complete and thorough handover

Inadequate highlighting of particular patients' needs during handover

Inconsistent handover processes failing to ensure adequate information sharing

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of review of wing log handover procedures

Concerns raised1

Lack of formalised handover procedures between controllers coming on and off shift

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 1

Actions described in response 1

Respondent positions 1

Actions described in response 1

Respondent positions 1