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
Distinct published reports
Individual concerns
41
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
50
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.
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
NHS trust19
Ministerial department5
Private limited company5
Executive agency4
Executive non-departmental public body4
Healthcare site3
Independent healthcare provider3
Prison or young offender institution3
Type not available3
Health and social care service regulator2
Integrated care board2
Police force2
Community interest company1
Company limited by guarantee1
Health and care professional regulator1
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.
East Riding and Hull
Concerns raised1
Failure to provide handover information between care shifts
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 concerns
Each 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
Action
Replace the paper diary with a structured handover process providing staff with shared resident information.
Stated by Westfield Residential HomeStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Action
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 September 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Stated by Care Quality CommissionNo action considered necessaryThe respondent said that no further action was needed.
Position
Inspection evidence identified no concerns with handover processes between staff.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cheshire
Concerns raised1
Failure to include recent drug-use information in shift handovers
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.
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
Action
Require material disclosures in handovers and MDTs, using an updated handover template with monthly senior-practitioner and registered-manager audits.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Dorset
Concerns raised1
Failure to ensure accurate and complete handover information
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 concerns
Each 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.11
Action
Strengthen Good medical practice standards on continuity of care, information sharing, safe delegation and handover responsibilities.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Analyse consultation responses on Leadership and management and Raising concerns guidance.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Develop updated Leadership and management and Raising concerns guidance following the consultation.
Stated by General Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Deliver outreach talks and workshops supporting implementation of professional standards, including communication, teamwork, information sharing and patient safety.
Stated by General Medical CouncilStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Explore opportunities to promote handover, continuity of care, teamwork and communication expectations through Outreach when promoting updated guidance.
Stated by General Medical CouncilStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Publish a guideline recommending structured patient handovers during transitions of care for adults receiving emergency and acute medical care.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Publish a quality standard requiring structured patient handovers during transitions of care for adults admitted with a medical emergency.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Develop and take SBAR-based inpatient handover guidance through internal governance.
Stated by Dorset Healthcare University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2026.
Action
Prioritise a robust, accurate, live handover function in the pan-Dorset electronic health record planned for 2028.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Scope handover processes across all mental health inpatient units by June 2026 to identify required changes.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Audit handover-related incidents across inpatient wards, report findings through governance groups, and monitor progress quarterly through March 2027.
Stated by Dorset Healthcare University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Existing guidance from the NMC, GMC, NHS England and CQC is sufficient, so further NICE guidance on handovers is unlikely to improve safety.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The NMC is responsible for responding to concerns about incorrect information handed over during a previous patient transfer.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
An additional general recommendation to include all pertinent information in written handover sheets is unlikely to be effective.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
Position
Existing professional standards adequately address communication, handover, record keeping, risk escalation and safe transfer of care.
Stated by Nursing and Midwifery CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Failure to hand over vital self-harm and ligature information at shift change
This report raised 30 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Implement electronic SBAR handovers to improve communication of patient safety information between shifts.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Bedfordshire and Luton
Concerns raised1
Failure to communicate relevant risk information through handovers and records
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.
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
Action
Strengthen shift handovers through clearer risk-information sharing expectations and allocated time for comprehensive handovers.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 3 October 2025.
Worcestershire
Concerns raised1
Failure of handover documents to communicate required personal-care staffing arrangements
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.
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
Action
Introduce key workers, alongside shift leads, to maintain knowledge of residents’ care needs and disseminate key information to teams.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Action
Review handover templates so they highlight key aspects of each resident’s care needs.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Action
Review handover sheets weekly and update them when residents’ care needs change, under management supervision.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 27 December 2024.
Suffolk
Concerns raised1
Inadequate handover arrangements for outstanding falls assessments between shifts
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 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.
Suffolk
Concerns raised1
Unavailability of a handover document between shifts for urgent referral downgrading
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Embed the updated handover document in East CRHTT practice.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 April 2024.
Action
Audit handover-document use monthly and report findings through local and Trust quality-assurance structures.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2024.
West Yorkshire Eastern
Concerns raised1
Failure to assure agency nurses’ competence, induction and handover
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 concerns
Each 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
Action
Share and discuss RCA findings with the nursing agency and implement a competency checklist signed by agency staff and the supplier.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Action
Provide deteriorating-patient training to agency staff through the supplier competency process.
Stated by Spire Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
Manchester South
Concerns raised1
Failure to complete and transfer adverse-event information through shift handovers
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Attend weekly ward shift handovers and check their content, accuracy and detail.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Disseminate safety bulletins across Priory hospitals reminding staff to record previous incidents in shift handovers.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Monitor handover quality through internal compliance and divisional quality inspections.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Introduce and trial an electronic handover template that consolidates patient and incident information and enables contemporaneous content audits.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
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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.
