Recurring concern

Unreliable handover of patients undergoing drug detoxification

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First reported 21 May 2018•Latest report 21 Jan 2019

Definition

What this concern includes

Includes failures of handover arrangements specifically covering patients undergoing drug detoxification, including identifying all relevant patients, reviewing their records, coordinating handover between detoxification and other healthcare staff, and communicating their needs and risks to incoming or responsible staff.

Not included

  • Excludes generic shift, ward or clinical handover failures where drug detoxification is not a material part of the asserted unsafe condition.
  • Excludes failures in detoxification assessment, treatment, monitoring or escalation where the detoxification-patient handover process is not deficient.
  • Excludes generic record-keeping, communication or staffing deficiencies unless they directly impair handover of patients undergoing drug detoxification.
  • Excludes handover failures concerning non-patient subjects or non-clinical operational processes.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2018–2019

First to latest report issue date

Stated actions
1

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham Community Healthcare NHS Foundation Trust1
Sirona care & health C.I.C.1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Neil Antony Black · 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 Antony Black was remanded into HMP Birmingham on 8 March 2018 after disclosing extensive alcohol and intravenous drug use and a DVT in his right leg. He became increasingly unwell in prison, was admitted to hospital on 12 March with suspected sepsis, and was diagnosed with infective endocarditis and lung abscesses before deteriorating to multi-organ failure and dying on 31 March 2018. The report identified concerns about inconsistent physical observations, inadequate interaction between prison healthcare teams, unclear responsibilities, and the lack of examination of his leg and injection sites.

    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 joint handovers between drug detoxification and primary care nurses

    Wider context from the report

    “1. BWing is the drug detoxification wing at Birmingham prison. Prisoners undergoing drug detoxification see IDTS nurses for drug needs and primary care nurses for health care needs. Prisoners on B wing often have complex mixed needs. The evidence at the inquest confirmed there were no joint handovers despite the nurses being located very close to each other. Consideration needs to be given to joint handovers to ensure those prisoners with joint needs have a coordinated approach. ”

    Source location

    Neil Antony Black · 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

    Implement joint midday handovers for patients requiring physical healthcare and substance misuse treatment, amend handover records, and audit the process.

    Verbatim wording from the response

    “We commenced a process on 11 February 2019 whereby the Nurse in Charge for both the “B3” team (the primary, or physical, healthcare team employed by BCHC) and the “IDTS” team (the Integrated Drug Treatment Service team employed by BSMH) have a verbal handover at the midday handover for any patients who are presenting as requiring joint care for both physical care and substance misuse treatment. The handover documents for both IDTS and B3 will be amended to ensure these patients discussed are recorded. This will be audited after one month to ensure the process is effective and any amendments to this process will be made.”

    Source location

    2019-0024-Response-by-Birmingham-Community-Healthcare-NHS-Trust
    Page 2 · response
    Published 23 May 2019

    Open published response

  2. Avon

    AI-generated summary

    Michalla Jane SWEETING · 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

    Michalla Jane Sweeting was a remand prisoner undergoing detoxification who was found unresponsive in her cell at 07.00hrs on 2nd June 2016. The medical cause of death was aspiration of gastric content in association with methadone toxicity. Concerns included inadequate response to reported over-sedation, unsatisfactory handover between shifts, inadequate clinical observations, and failures in communication and assessment.

    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 include all prisoners/patients undergoing detoxification in handover

    Wider context from the report

    “1. Handover: a. That the handover includes all prisoners/patients undergoing detoxification. b. That the handover is the responsibility of the registered nurse c. That it includes a review of the records for the shift by that registered nurse – this was raised by ████████ and was reflected in the jury conclusion. I therefore report this to you for your consideration in preventing future deaths ”

    Source location

    Michalla Jane SWEETING · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026