Recurring concern

Unreliable shift handover processes

First to latest report 21 Nov 2013 — 26 Jun 2026

Reports that mention this concern
36
Times this concern has been raised
41
Stated actions linked to this concern
50

What this concern includes

Includes failures of shift-change handover processes, including incomplete handover content, failure to review or communicate relevant information, and premature destruction or unavailable handover records where this impairs reference by responsible staff.

What is not included
  • Excludes clinical handover failures between services or teams where no shift-change handover process is identified.
  • Excludes generic record-retention deficiencies involving records unrelated to shift handover.
  • Excludes failures of patient observations, care delivery or escalation where the shift-handover process is not itself deficient.
  • Excludes generic communication or documentation deficiencies that are not specifically part of a shift-change handover.

Reports and published responses 36 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    Milly ZEMMEL · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Milly ZEMMEL, who was blind and aged 89, was admitted to hospital after becoming unwell and later suffered falls, including an unwitnessed fall on 1 March 2015 while experiencing acute confusion. She fractured her left femur, was not considered fit for surgery, and died on 3 March 2015. The principal concerns were failures in falls-risk assessment, escalation and handover after an earlier fall, appropriate supervision and observations, and the adequacy of the hospital’s internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to hand over important clinical information to the next shift

    Wider context from the report

    “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death. ”

    Source location

    Milly ZEMMEL · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to check patient records for up-to-date information at shift change

    Wider context from the report

    “4. There was a gross failure to initiate appropriate one to one supervision and observations for the deceased from the early hours of the morning on 1 March 2015. In addition there was a failure to ensure that important clinical information about the deceased’s condition was handed over to the next shift. Nor did the next shift nurse in charge ensure that the deceased’s records were checked to find out what the up to date information on the situation was. Consequently the deceased, who was suffering an acute confusional state, and who was blind was left unsupervised for several hours leading her to have a fall and suffer a serious injury which caused or contributed to her death. ”

    Source location

    Milly ZEMMEL · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce Safety Huddles at the start of ward and departmental shifts to discuss incidents, safety issues and enhanced observation needs.

    Verbatim wording from the response

    “The Trust has piloted and now introduced a ‘Safety Huddle’ at the commencement of each ward and departmental shift which includes the discussion and handover of any recent incidents, as well as safety issues relating to patients. This includes a prompt for discussion of any patients who will require additional observation or enhanced supervision as part of their care. This allows nursing staff to report on any unexpected and significant events involving patients and helps them to proactively plan and agree how to resolve them. The policy is within Appendix 2 - Safety Huddle document.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Launch and disseminate the Clinical Communication and Handover Policy with structured escalation and handover documentation.

    Verbatim wording from the response

    “The Trust launched a policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concerns such as a patient who may be at risk of falls information and a standard framework for escalating concerns about a patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed. The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality and level of compliance. This policy is within Appendix 3 - Clinical Communication and Handover Policy.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct quarterly audits of compliance with the Clinical Communication and Handover Policy.

    Verbatim wording from the response

    “The Trust launched a policy for Clinical Communication and Handover in September 2015 which includes handover documentation templates with more robust information for recording safety concerns such as a patient who may be at risk of falls information and a standard framework for escalating concerns about a patient. The policy also includes the standard required for doctor to doctor handovers including for patients who have been referred and who need to be assessed. The policy has been disseminated across the clinical teams in the Trust and the senior nursing team undertake quarterly audits to assess the quality and level of compliance. This policy is within Appendix 3 - Clinical Communication and Handover Policy.”

    Source location

    2016-0139-Response-Pennine-Acute-Hospitals
    Page 2 · response
    Published 6 April 2016

    Open published response

  2. Manchester South

    AI-generated summary

    Ranjan Raman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    The report states that the deceased was admitted to hospital with low sodium levels and high blood pressure, fell three times, and sustained a head injury followed by a fatal bleed. Concerns included insufficient falls-risk assessment, missing or incomplete neurological observation charts, poor communication between medical and nursing staff, destruction of shift hand-over sheets, and inadequate incident-report details.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to retain shift hand-over sheets

    Wider context from the report

    “4. The hand-over sheets for each shift were being shredded by the nurses as soon as the shift was completed. Whilst it is appreciated that these cannot be placed on the record of an individual patient for reasons of confidentiality, there is no reason why they could not be filed on the wards and retained for say 14 days which would allow further reference to be made to them, should this be deemed necessary or helpful. ”

    Source location

    Ranjan Raman · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Consider introducing electronic archiving of ward and departmental handover sheets.

    Verbatim wording from the response

    “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

    Source location

    R-Mistry-Response
    Page 3 · response
    Published 4 March 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Paper handover sheets are not archived because confidentiality and maintaining reliance on the current sheet create practical constraints, although electronic archiving may be introduced.

    Verbatim wording from the response

    “The Coroner’s observations are noted and the Trust acknowledges that the Trust does not keep an archived copy of handover sheets, this is for many reasons including confidentiality and to ensure that the sheet being referred to is an up to date one and not one from a previous date. However following the Coroner’s observations the Trust recognises that there is no reason why handover sheets which are electronically produced could not be electronically archived to provide a record of what information was being communicated at handover at a point in time. This would as the Coroner observes provide a record should it be necessary to refer to them.”

    Source location

    R-Mistry-Response
    Page 3 · response
    Published 4 March 2016

    Open published response

  3. Manchester South

    AI-generated summary

    Freda Weston · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Freda Weston was treated for septic arthritis in a replacement knee and died in hospital on 29 April 2015. The report states that Septrin led to disseminated intravascular coagulation and identifies concerns including delays in antibiotics, insufficient time to assess whether the new drug suited her, inadequate staffing, and failures in communication and escalation procedures.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to retain ward handover sheets for reference

    Wider context from the report

    “9. The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete. ”

    Source location

    Freda Weston · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide electronic handover access across Medicine Business Group wards, enabling retrospective access to patient handover information.

    Verbatim wording from the response

    “I can confirm that all wards in the Medicine Business Group have access to an electronic handover. Staff print these for each shift so they can be viewed as they move around the wards. The handover sheets are shredded at the end of each shift to make sure information is not taken home by staff, which would compromise patient confidentiality and make sure that incorrect information is not used on the ward. The information, per patient, can be accessed electronically retrospectively.”

    Source location

    Weston-Response
    Page 4 · response
    Published 23 February 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Electronic handover records can be accessed retrospectively, so retaining shredded paper handover sheets is unnecessary and risks confidentiality and outdated information.

    Verbatim wording from the response

    “9) The handover sheets on the ward are “shredded by the nurses” immediately after handover. Why cannot these be kept in a folder on the ward for at least 14 days should they be needed for reference purposes? I was told of the transition from paper to electronic notes. This seems to have been happening for a very long time and one wonders when it will be complete.”

    Source location

    Weston-Response
    Page 4 · response
    Published 23 February 2016

    Open published response

  4. Manchester West

    AI-generated summary

    Mollie Bentham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct effective shift handovers between nursing and medical staff

    Wider context from the report

    “1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”

    Source location

    Mollie Bentham · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop standard operating procedures for information handover.

    Verbatim wording from the response

    “Standard Operating Procedures (SOP) have been developed with regard to improving the handover of information. The Daily Safety Huddle which takes place every morning now includes the doctor and a senior member of the therapy team. In addition, the senior Sister at Darley Court has been reviewing the efficiency of the handover process at the end of and commencement of a shift. Further improvements are identified these will be included in the SOP for handovers.”

    Source location

    Mollie-Bentham-Response
    Page 2 · response
    Published 30 December 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review handover efficiency at shift changes and incorporate identified improvements into the handover procedures.

    Verbatim wording from the response

    “Standard Operating Procedures (SOP) have been developed with regard to improving the handover of information. The Daily Safety Huddle which takes place every morning now includes the doctor and a senior member of the therapy team. In addition, the senior Sister at Darley Court has been reviewing the efficiency of the handover process at the end of and commencement of a shift. Further improvements are identified these will be included in the SOP for handovers.”

    Source location

    Mollie-Bentham-Response
    Page 2 · response
    Published 30 December 2015

    Open published response

  5. North Wales (East and Central)

    AI-generated summary

    Alan Walker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Alan Walker died after a nasogastric feeding set was connected to an intravenous line, resulting in the infusion of liquid feed. The report raised concern that equipment connectivity issues were not recorded in nursing notes and might not be relayed during staff handovers.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct handovers by reference to nursing notes

    Wider context from the report

    “That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time. ”

    Source location

    Alan Walker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Elsie Marjorie Brown · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide formal paid handover time within staff shifts

    Wider context from the report

    “9. Handovers were not regarded as integral to the staff’s paid shift and were informal and unpaid. ”

    Source location

    Elsie Marjorie Brown · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Alter shift patterns to create overlap for a protected, paid handover.

    Verbatim wording from the response

    “The Company has always recognised the importance of handovers as part of the daily routine for operating a service that runs 24 hours a day, 365 days a year. We are keen to ensure that the handover is a protected part of the day and is not interrupted in any way. We have consulted with staff and altered their shift patterns with effect from 21st January 2015, to ensure that we have an overlap of shifts which allows for a paid handover to take place to relay information about the people we are provided care and support to. We feel this will formalise the current system and make our handover process more robust.”

    Source location

    Elsie-Brown-Response
    Page 4 · response
    Published 4 December 2015

    Open published response

  7. Manchester South

    AI-generated summary

    Elsie Clarke · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide full and effective shift handover

    Wider context from the report

    “(8) There was a failure to give full and effective “hand-over” at each shift change. ”

    Source location

    Elsie Clarke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Introduce a shift-change handover process for sharing key information.

    Verbatim wording from the response

    “Action taken A new handover process has been introduced which enables staff to share key information at the changeover of every shift. In addition, the Home Manager holds daily flash meetings with all members of the team to update them on any significant changes and identify any specific events or activities required that day. The flash meeting also updates the team on any Residents who require close monitoring. These meetings are documented and the records are held in the Care Home for review.”

    Source location

    Elsie-ClarkeR
    Page 3 · response
    Published 20 August 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Hold and document daily flash meetings to communicate significant changes and identify required activities and residents needing close monitoring.

    Verbatim wording from the response

    “Action taken A new handover process has been introduced which enables staff to share key information at the changeover of every shift. In addition, the Home Manager holds daily flash meetings with all members of the team to update them on any significant changes and identify any specific events or activities required that day. The flash meeting also updates the team on any Residents who require close monitoring. These meetings are documented and the records are held in the Care Home for review.”

    Source location

    Elsie-ClarkeR
    Page 3 · response
    Published 20 August 2015

    Open published response

  8. South Yorkshire (Western)

    AI-generated summary

    Neil Budziszewski · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Neil Budziszewski was arrested for theft while intoxicated and detained overnight at Ecclesfield Police Station after being charged. He was found dead in his cell before being transferred to court. The report identified numerous failures involving risk assessment, communication and handovers, monitoring, recording, and obtaining medical assessment, including failures to recognise and respond to the risks of acute alcohol withdrawal syndrome.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to review custody records and risk assessments at shift commencement

    Wider context from the report

    “(18) The oncoming (night) custody sergeant failed to review the custody record or risk assessment when he came on duty. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Incomplete handover of detainee health risks and observation requirements

    Wider context from the report

    “(16) The handover from the afternoon custody sergeant to night custody sergeant did not include information about Mr Budziszewski being prescribed Methadone, that he was an alcoholic, or that he was on 30 minute checks. This was accepted not to be a full and effective handover. ”

    Source location

    Neil Budziszewski · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Document and standardise custody handover requirements, including transfer of risk-assessment information.

    Verbatim wording from the response

    “The process for handovers is now documented and is consistent across the force. The process is that the sergeant handing over will summarise to the incoming sergeant personal information about the detainee, details of the offence and the stage of the investigation and any specific risk factors. The focus of the handover is to be around the risk assessment which has been completed. Appendix C shows a completed copy of the handover Sergeants are expected to complete. As this is a live copy, third party data has been redacted out to ensure compliance with the Data Protection Act.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 5 · response
    Published 23 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Regularly train current and new custody staff on the standardised handover process.

    Verbatim wording from the response

    “Unfortunately this was an example of extremely poor recording keeping. That cannot be defended however it is certainly below the expectations of South Yorkshire Police. The custody staff involved have all been spoken to following the inquest and advised of this issue and told of the expectations upon them. It is also anticipated that the new handover process should ensure this does not happen going forward and this process will be regularly trained to custody staff, current and new.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 8 · response
    Published 23 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing custody training and practices comply with Home Office standards; the identified failures were attributed to individual officer error rather than deficient arrangements.

    Verbatim wording from the response

    “Whilst Mr Budziszewski was at Bridge Street custody he was not cooperative with the risk assessment process. In any event this should have been reviewed upon his return to Ecclesfield. Custody staff are aware of the importance of the risk assessment and the requirement to regularly review where information is missing and therefore this failure on this occasion is down to officer error and not due to an issue with the training and practices. Appendix A refers to the new risk assessment which has been in force since October 2014.”

    Source location

    2015-0109-Response-by-South-Yorkshire-Police
    Page 2 · response
    Published 23 March 2015

    Open published response

  9. Southampton and the New Forest

    AI-generated summary

    Daniel Stickland · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Daniel Stickland, aged 17, was found collapsed after falling from his bed at his residential school on 14 May 2014, following two seizures earlier that day. He was taken to hospital and pronounced dead the following day; concerns included inadequate handovers, inaccurate or inaccessible logs, and no clear central method for recording significant medical events.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of a written handover between evening and night supervisors

    Wider context from the report

    “(1)Lack of a written handover between evening and night supervisors at St Edwards School ”

    Source location

    Daniel Stickland · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. London (East)

    AI-generated summary

    Mrs Awa Jeng · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Awa Jeng was admitted after a fall that caused a fractured left hip and underwent surgery. She subsequently required dialysis but was not adequately monitored on the ward, and tests were delayed until her potassium was at a life-threatening level. She deteriorated, suffered cardiac arrest during intubation, and could not be resuscitated; the inquest concluded that inadequate monitoring and delayed haemofiltration contributed to her death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of handover of responsibilities and tasks between day and night shifts

    Wider context from the report

    “6. I note that the Trust’s internal investigation raised concerns in relation to the handover of responsibilities and tasks between day and night shifts. There is however currently no clear action to address this concern. ”

    Source location

    Mrs Awa Jeng · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add signing and dating requirements to orthopaedic handover sheets and retain them for audit and transparency.

    Verbatim wording from the response

    “There is a formal list and documentation for this meeting, an action plan for each patient and a record is kept and recorded on the sheet. This document forms the basis for the formal face-to-face handover meeting between the day and night medical teams.”

    Source location

    2015-0015-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 20 January 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Send written and verbal instructions requiring junior doctors to record out-of-hours review needs on the trauma sheet before ending shifts.

    Verbatim wording from the response

    “Instructions verbally and written have been sent to all junior doctors in orthopaedics and orthogeriatrics regarding their responsibilities to add details of any patient requiring review out of hours to the trauma sheet before finishing their shifts.”

    Source location

    2015-0015-Response-by-Barts-Health-NHS-Trust
    Page 3 · response
    Published 20 January 2015

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026