1. Purpose
This policy sets out how the Service completes safe transfer of care at the end of each ambulance job, records handover and responds to delayed, missing or incorrect handover.
The policy applies to planned transport, high-dependency transfer, urgent transport and event-cover work where the Service hands a patient to another service, facility or responsible person.
2. Sources to verify before adoption
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17: https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
- NHS England, reducing hospital handover delays: https://www.england.nhs.uk/urgent-emergency-care/improving-ambulance-services/reducing-hospital-handover-delays/
- NHS England, guidance for emergency departments, initial assessment: https://www.england.nhs.uk/guidance-for-emergency-departments-initial-assessment/
- Current JRCALC clinical practice guidelines and handover standards, held or accessed by the Service through its own subscription or local arrangement.
3. Scope
This policy applies to:
- hospital-to-hospital transfer
- hospital-to-home discharge transport
- clinic and outpatient transport
- high-dependency transfer accepted by the Service
- event medical cover where a patient transfers to another provider
- urgent or private ambulance jobs where handover is required
- handover to a ward, clinic, emergency department, home address, care home, hospice or other receiving service
- handover paperwork, electronic records and verbal handover
- delayed handover, missing paperwork and wrong destination transfer
The policy applies to NHS-contracted journeys, private journeys and subcontracted journeys where the Service remains responsible for the handover process.
4. Transfer-of-care process
Crew complete transfer of care at the receiving destination before closing the job.
4.1 Before arrival
Crew check the destination before arrival.
The check covers:
- receiving facility or home address
- receiving ward, department, clinic or named contact
- expected arrival time
- patient acuity and monitoring need
- patient mobility and equipment needed for unloading
- documents or medicines travelling with the patient
- infection prevention information
- safeguarding or behaviour concern where relevant
- escort or family contact where relevant
If Crew identify a destination mismatch before arrival, they contact the control point before continuing unless stopping would create greater risk.
4.2 Verbal handover
Crew give a verbal handover to the receiving clinician, receiving staff member or agreed responsible person.
The handover includes:
- patient identity
- journey or incident completed
- collection point
- destination
- reason for transport or treatment
- observations, treatment or changes during the job where relevant
- medicines, oxygen or equipment handed over
- mobility and transfer information
- comfort, communication or safeguarding information relevant to immediate care
- any deterioration, refusal, delay or incident during the job
Crew keep the handover factual and concise. They do not add information they have not received or directly observed.
4.3 Documentation handover
Crew check that required documentation has moved with the patient.
Documentation may include:
- transport booking record
- clinical record or patient report form
- transfer letter
- discharge paperwork
- medicines list
- DNACPR, ReSPECT or advance care planning document where supplied
- mobility or moving-and-handling plan
- oxygen information
- safeguarding information where lawful and relevant
- property record
Crew record what documentation was handed over, who received it and any missing paperwork.
4.4 Handover after event cover
For event-cover work, Crew hand over to the receiving ambulance service, emergency department, event medical lead or other agreed receiving service.
The record includes:
- event location
- patient presentation
- treatment given within scope
- observations where recorded
- medicines administered
- reason for transfer
- receiving service or clinician
- time transfer requested
- time transfer completed
The Service does not close the event record until the receiving route and handover have been documented.
5. Delayed handover
The Service treats delayed handover as a governance issue and a possible patient-safety issue.
Where handover is delayed for more than 30 minutes, Crew record:
- arrival time
- time handover completed
- reason given for delay
- patient condition during the wait
- escalation calls made
- welfare needs met during the wait
- impact on vehicle availability and the next booked job
The Operations Manager escalates repeated delayed handovers at the same receiving facility to the commissioner or relevant contact where the contract allows it. The Registered Manager reviews patterns as Regulation 17 governance evidence.
6. Missing paperwork and wrong destination transfer
6.1 Missing handover paperwork
If required paperwork is missing, Crew do not invent or reconstruct clinical information.
Crew:
- tell the receiving person what is missing
- contact the referring facility or control point
- record what was missing
- record advice received
- record whether the patient was accepted by the receiving facility
- complete an incident record where missing paperwork creates risk, delay or complaint
The review checks whether the booking process, collection process or referring facility caused the gap.
6.2 Wrong destination transfer
If Crew identify a wrong destination before, during or after arrival, they escalate immediately.
Crew:
- keep the patient safe and informed where appropriate
- contact the control point
- confirm the correct destination with the booking source
- seek clinical advice where delay or movement creates risk
- record the error and patient impact
- complete an incident record
The Registered Manager reviews whether duty of candour, commissioner notification, safeguarding, complaint handling or CQC notification advice is needed.
7. Responsibilities
- Registered Manager: owns this policy, ensures handover governance is reviewed and signs off annual review.
- Lead Clinician: advises on clinical handover content, deterioration during delayed handover and clinical-risk escalation.
- Operations Manager: manages destination checks, delayed handover escalation, control-point support and pattern review by facility.
- Crew: complete verbal and documented handover, record delays and escalate missing paperwork or destination mismatch.
- Booking staff or control staff: record destination, receiving contact, required documents and handover requirements before dispatch.
- All staff: record handover incidents promptly and use the improvement action process for repeat themes.
8. Recording requirements
The Service keeps the following records:
- booking or job record
- destination and receiving contact
- patient report form or clinical record where applicable
- handover completion record
- documents handed over
- delayed handover record
- missing paperwork record
- wrong destination transfer incident
- patient condition change during handover delay
- escalation calls
- complaint link where applicable
- commissioner communication where applicable
- improvement action record
Records are kept in the Service governance records and are available for internal review, CQC review, commissioner review and external review where required.
9. Audit cadence
The Service uses the following Verivius default audit rhythm unless current CQC, JRCALC, NHS England, commissioner or local source material requires a different rhythm:
- Per job: Crew record handover completion before the job is closed.
- Weekly: the Operations Manager reviews delayed handovers, missing paperwork and wrong destination concerns.
- Monthly: the Lead Clinician reviews any handover linked to deterioration, incomplete clinical information or patient harm.
- Quarterly: the Registered Manager reviews patterns by receiving facility, booking source, crew mix and route.
- Annually: the Service audits this policy against current source material and updates the handover standard.
Audit findings are recorded as improvement actions with an owner and review date.
10. Version control and review date
The Service keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Booking record
- Job record
- Patient report form
- Handover record
- Incident register
- Complaint register
- Duty of candour policy
- Vehicle defect, MOT and roadworthiness policy
- Controlled drugs and vehicle medicines policy
- Improvement action register
- Commissioner communication record
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.