Recurance · prevention of future deaths reports
Pre-inquest brief
Inadequate shift handover communication leading to missed critical patient details
The earlier warning
James Francis · 19 Jun 2019 · Penelope Schofield, West Sussex
“both key support workers who knew Mr [name redacted] best failed to carry out the 30 minute observations during the morning and afternoon shifts”
judiciary.uk/prevention-of-future-death-reports/james-francis
What was promised
Stated action 1 · response to James Francis (19 Jun 2019) · stated timescale: September 2019
“The guideline is currently undergoing a surveillance review exercise to determine whether It should be updated As a result of your report, the review Is likely to conclude that an update is required so that it is clearer that the guideline applies to indirect head injury (for example, by making the definition more accessible to users) A final surveillance review decision Is due to be published in September 2019”
What recurred
- 12 Feb 2026 · James Fitzpatrick · Rachael Griffin · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · James Francis · 19 Jun 2019
“both key support workers who knew Mr [name redacted] best failed to carry out the 30 minute observations during the morning and afternoon shifts”
Later · James Fitzpatrick · 12 Feb 2026
“pertinent general information about [name redacted] was missing from that handover sheet”
What happened next
No web check of the stated actions has been published for this chain.