Incomplete handover documentation

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.

• 2015 → 2017Patricia Webb1 year 11 months after Evelyn Kennedy · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify problems with patient handover processes. The earlier report describes handover as incomplete and unhelpful, while the later report criticises handover for relying on inadequate tick‑box notes that fail to capture individual patient needs.

  Evelyn Kennedy · 7 May 2015

  “Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. | (4) She arrived unkempt”

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  Patricia Webb · 20 Apr 2017

  “handover relies more and more on the notes and the notes are relying more and more on tick boxes which are simply not adequate to deal with the individualities of each patient.”

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  Stated action in the response to the earlier report

  “The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”

  Earlier report in the app · Later report in the app

• 2015 → 2018Joan Blaber3 years 5 months after Evelyn Kennedy · same coronerClosely relatedConfidence 0.80 · moderate

  Closely relatedConfidence 0.80 · moderate

  Both reports highlight failures in communication that compromise patient safety.

  Evelyn Kennedy · 7 May 2015

  “(3) Handover was incomplete and unhelpful. |”

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  Joan Blaber · 1 Oct 2018

  “Failure in training and post training monitoring for Trust staff and lack of control over training for agency staff using hazardous substances. Failures in supervisory staff in the housekeeping department (particularly those on the fourth floor of the Thomas Kemp Tower) to adhere to their own practices and requirements eg.”

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  Stated action in the response to the earlier report

  “The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”

  Earlier report in the app · Later report in the app

• 2015 → 2019Kenneth Whittington3 years 9 months after Evelyn Kennedy · same coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight failures in providing adequate handover information when a patient moves between care settings.

  Evelyn Kennedy · 7 May 2015

  “Handover was incomplete and unhelpful.”

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  Kenneth Whittington · 14 Feb 2019

  “His discharge documentation which acts as a handover for his Doctors was barely completed and this lack of completion is unacceptable.”

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  Stated action in the response to the earlier report

  “The Trust introduced a new clinical management structure last autumn, a very few weeks before Mrs [name redacted] last admission. The clinical team now managing the acute medical unit have worked tirelessly to introduce a range of changes in order to improve the functioning and quality of the Acute Medical Unit. These incorporate a range of actions relating to the workforce, education, environment, equipment, patient flow, teamwork and communications.”

  Earlier report in the app · Later report in the app

• 2014 → 2019Kenneth Whittington4 years 10 months after Graham Watts · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight inadequate discharge documentation that fails to provide proper handover information. The earlier report describes blank paperwork, while the later report notes barely completed documentation.

  Graham Watts · 3 Apr 2014

  “(1) That the Discharge procedure followed in respect of Mr. [name redacted]' discharge from the Princess Royal Hospital in Haywards Heath, West Sussex on the 4”

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  Kenneth Whittington · 14 Feb 2019

  “(6) Mr. [name redacted] was due to be discharged on the 4”

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  Earlier report in the app · Later report in the app

• 2017 → 2019Kenneth Whittington1 year 10 months after Patricia Webb · same coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports highlight inadequacies in handover documentation, noting that reliance on notes or tick‑box systems fails to capture individual patient needs.

  Patricia Webb · 20 Apr 2017

  “handover relies more and more on the notes and the notes are relying more and more on tick boxes”

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  Kenneth Whittington · 14 Feb 2019

  “Mr. [name redacted] was due to be discharged on the 4”

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  Earlier report in the app · Later report in the app