Inadequate shift handover communication leading to missed critical patient details

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2019 → 2026James Fitzpatrick6 years 8 months after James Francis · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight failures in communicating essential patient information during handovers, leading to missed critical details. The earlier case concerns verbal shift handover meetings omitting observation requirements; the later case concerns incomplete written handover sheets for agency workers.

  James Francis · 19 Jun 2019

  “both key support workers who knew Mr [name redacted] best failed to carry out the 30 minute observations during the morning and afternoon shifts”

  Check it in the source

  James Fitzpatrick · 12 Feb 2026

  “pertinent general information about [name redacted] was missing from that handover sheet”

  Check it in the source

  Stated action in the response to the earlier report

  “The guideline is currently undergoing a surveillance review exercise to determine whether It should be updated As a result of your report, the review Is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users) A final surveillance review decision Is due to be published in September 2019”

  Earlier report in the app · Later report in the app