Regan Smith
24 Jul 2024 · Coroner Nigel Parsley · Suffolk
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. delayed or missed critical clinical information
“The information to save [the deceased]'s life (his abnormal blood glucose reading) was in the possession of the NHS at a time when lifesaving treatment could have been given to him on the 25th January 2023”
2. ineffective handover process
“[the deceased]'s death occurred as the result of an identifiable single point of failure (the ineffective handover process), as this led to a significant and known clinical finding being unavailable to his treating clinicians”
3. absence of national handover standards
“there was no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, in relation to the conduct of patient handovers at Accident and Emergency Units”
4. missing confirmation of observations handover
“there is no national protocol, no national standard operating procedures, and no National Institute for Health and Care Excellence guidance, to ensure basic observations are confirmed as being handed over by ambulance personnel, and confirmed as being received by the receiving Accident and Emergency personnel”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“When Mr [name redacted] was admitted to A & E on the 13”
This report
“Evidence heard that the handover system in [the deceased]'s case was reliant on both ambulance and Accident and Emergency personnel making and receiving a verbal handover.”