Inadequate face to face medical handover of patient information

Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals. ?Every quote shown was checked by code to appear word for word in the original report.

• 2013 → 2016Tommi-Ray Vigrass2 years 6 months after Stephanie Daniels · different coronerClosely relatedConfidence 0.90 · high

  Closely relatedConfidence 0.90 · high

  Both reports identify failures in the handover of critical patient information between staff members. The earlier report focuses on general nursing‑clinical handover, while the later report concerns handover specifics for a premature baby’s transfer.

  Stephanie Daniels · 13 Dec 2013

  “All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care.”

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  Tommi-Ray Vigrass · 28 Jun 2016

  “There was also evidence of an inadequate handover and preparation for the arrival of the premature baby with insufficient care plan details or consultation taking place.”

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  Earlier report in the app · Later report in the app

• 2017 → 2018Tom Cribley1 year 3 months after James Allbones · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight the absence of a proper face‑to‑face medical handover process. They describe the same specific hazard concerning communication of patient information between clinicians.

  James Allbones · 21 Jul 2017

  “that there is still no protocol for face to face medical handover”

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  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”

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  Earlier report in the app · Later report in the app

• 2013 → 2018Tom Cribley4 years 10 months after Stephanie Daniels · different coronerIdentical hazardConfidence 0.90 · high

  Identical hazardConfidence 0.90 · high

  Both reports highlight failures in the handover of clinical information between staff. The earlier report notes missing requirements for nurses to review patient records at transfer, while the later report describes failures to handover concerns face‑to‑face.

  Stephanie Daniels · 13 Dec 2013

  “For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records.”

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  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”

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  Earlier report in the app · Later report in the app