James Fitzpatrick

1. 1. lack of written national guidance on handover

   “There is a lack of written national guidance on how handovers between Doctors, Nurses and support staff should be undertaken either when a patient is moved between wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the care of the person. Whilst it is acknowledged that each Trust has different policies and procedures in place, there is no generic national guidance to assist in ensuring relevant, pertinent and critical information is passed on to those who will be caring for the patient.”

2. 2. absence of guidance for non-emergency settings

   “Evidence was provided that national guidance currently exists in England and Wales for handovers relating to emergency care in acute hospitals, however there is no other guidance for other healthcare settings as to what a handover should include or how it should be undertaken.”

3. 3. lack of local written guidance

   “Within DHUFT there is a lack of written guidance or policy as to how handovers should be undertaken and recorded by those working within the Trust.”

4. 4. inaccurate risk information recorded

   “Two weeks prior to his death, [name redacted] was moved to another ward within Alderney Hospital. There was a verbal handover undertaken which was recorded in the electronic patient records. No written handover was provided. The patient records referred to him being a "high risk of choking" and "on an unofficial soft diet". This information was not true and was not recorded anywhere else in his records or risk assessments.”

5. 5. missing critical patient information in handover sheet

   “Further evidence was given that at the time of [name redacted]'s death there were a number of agency workers at Alderney Hospital, and they would rely on information provided to them at the start of their shift during the handover as they would not have time to go through each patient's records to appraise themselves of the patient's history and risks. A daily written handover sheet was provided at the beginning of each shift which would be updated during the day, however from the daily handover sheet provided to the Court for the day of [name redacted]'s death, pertinent general information about [name redacted] was missing from that handover sheet.”

6. 6. risk of future death due to handover failures

   “The lack of written local and national guidance on the handover of a patient's care creates a risk that incorrect or incomplete information can be passed to those caring for an individual which may impact upon the patient's care and may lead to a future death.”

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