Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate face to face medical handover of patient information
The earlier warning
Stephanie Daniels · 13 Dec 2013 · Nigel Meadows, Manchester City
“All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care.”
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 28 Jun 2016 · Tommi-Ray Vigrass · Zafar Siddique · Closely related · confidence 0.90 (high)
- 21 Jul 2017 · James Allbones · Elizabeth Didcock
- 9 Oct 2018 · Tom Cribley · Julie Goulding · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · James Allbones · 21 Jul 2017
“that there is still no protocol for face to face medical handover”
Later · Tom Cribley · 9 Oct 2018
“the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers”
What happened next
No web check of the stated actions has been published for this chain.