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 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.
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
Use ward allocation boards, shift planners, staff identification boards and minimum handover standards to communicate patient allocations and status to incoming staff.
Stated by Devon Partnership NHS 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
Existing policies, standards and guidance address the concerns; new standards are not required, though further assurance actions will be implemented.
Stated by Devon Partnership NHS Trust
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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.
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 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.
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 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
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.
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
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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.
Stated by Department of Health and Social Care
Data last updated 7 September 2026