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Fatal communication failure

01 September 2008

Mrs D, a 63-year-old theatre director, was admitted to her local district general hospital after a short illness characterised by anorexia, vomiting and severe colicky abdominal pain.

She was assessed in the emergency department by Dr L, registrar in emergency medicine. Dr L felt that Mrs D was suffering from sub-acute small intestinal obstruction of uncertain aetiology, but that her condition was not life-threatening. He thought that Mrs D was stable and suitable for pro tem observation and conservative management on a surgical ward. Dr L referred Mrs D to the on-call surgical registrar, Mr A. The handover was brief and conducted by telephone, as Mr A was in theatre. Mr A had long been a colleague of Dr L and trusted his judgement, so was happy for Mrs D to be transferred to the surgical ward.

Mr A asked Dr L to pass on a message to the ward staff to request that the surgical SHO assess Mrs D and pass a nasogastric tube when she arrived on the ward. Mrs D was not seen by the surgical SHO on her arrival on the ward, as Dr L forgot to impart this information to the nursing staff on the handover form on the front of her notes. Nor was a naso-gastric tube passed. Dr L had requested on the handover form that she have hourly vital signs observations and monitoring of her urinary output. Mrs D had her vital signs checked on arrival on the ward but then received no further observations. Six hours after her admission to the ward, in the early hours of the morning, a neighbouring patient attracted the attention of a nurse to the fact that Mrs D appeared to be very ill.

Mrs D suffered a cardiac arrest shortly afterwards and could not be resuscitated. A post-mortem revealed a right-sided obstructed, necrotic femoral hernia. Mrs D’s family launched a legal claim against Mr A, Dr L and the nursing staff on the surgical ward, alleging negligence through insufficient assessment and observation.

Expert opinion

A general surgical expert felt that it was unlikely that Mrs D’s condition was quite as benign as Dr L had thought on her admission to hospital, but that a rapid deterioration could not be ruled out. Mr A was criticised for not normally assessing Mrs D at any point in the night, or ensuring that he asked a member of his team to do so.

It was felt that handing that responsibility over to Dr L was inappropriate and liable to lead to error. A surgical nursing expert was critical in his assessment of the actions of the ward nursing staff. They should have ensured that they conducted observations as requested on the handover form and asked a member of the surgical team to assess Mrs D after her admission to the ward.

Mrs D was, in effect, left unobserved for nearly six hours. Although there was no note anywhere in the clinical record that she needed to be assessed by a member of the surgical team on arrival on the ward, this was standard practice at the time on the unit. The handover sheet from the A&E department clearly stated that she needed to have a naso-gastric tube passed, which was not performed by the nursing staff, nor was a member of the surgical team asked to perform this intervention, which may have given a chance of her being re-assessed.

The claim was settled for a moderate sum.

Learning points

  • It is imperative that there are formalised handover procedures between departments when patients are admitted to hospital. This is particularly true given the international trend to reduce the working hours of junior doctors and therefore increase the number of handovers.
  • Careful documentation and completion of observations, need for further assessment and the ongoing management plan are essential to avoid patients falling through holes in the system, as happened to Mrs D.
  • It is important to remember that, when patients have been handed over to you, they become your responsibility. It is good practice to make your own judgement on the patient’s condition, no matter how trusted the colleague who has passed them on to you.
  • Wards should have robust systems to ensure that any requested actions of nursing staff are acknowledged, acted upon and documented as having been carried out, when patients are admitted, especially as emergency cases.

Further reading

  • Safe Handover: Guidance from the Working Time Directive Working Party, The Royal College of Surgeons, (2007).
  • Safe Handover: Safe Patients, BMA, (2004).