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An ST1 doctor reached the end of his shift on a general surgical ward. A few hours earlier he had requested a U and E blood test for a patient with a suspected bowel obstruction but had not yet heard back from the lab. The doctor was in a hurry and left a written note for a colleague on the next shift to chase the results. He went off duty for the weekend. When he returned on Monday, the note had gone and the ST1 assumed the test results had been actioned. However, he later discovered that the patient had suffered an acute kidney injury and been admitted to intensive care with multiple organ failure. Extremely distressed, the doctor contacted the MDU for advice.
Effective communication is essential for safe handovers, as well as being an ethical duty. In paragraph 44 of Good medical practice (2013), the GMC states that doctors "must contribute to the safe transfer of patients between healthcare providers". It specifically requires them to "share all relevant information with colleagues involved in your patients' care within and outside of the team, including when you hand over care as you go off duty" and to "check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient's care has ended."
To his credit, the ST1 already accepted he was at fault for leaving the shift without talking to another doctor about the tests and ensuring they would follow this up in his absence. He should now be open and honest with his consultant about what had happened and contribute to any inquiry into the adverse incident, in line with paragraph 23 of Good medical practice (2013). He should also apologise to the patient and their family if he has the opportunity.
While this could only be limited consolation, the ST1 was not alone. Several studies have shown that rushed, informal handovers are a common factor in SUIs in the UK. The GMC says that doctors in a leadership role have an ethical duty to "make sure that each patient's care is properly co-ordinated and managed" and to "be satisfied that systems are in place to communicate information about patient care". This case showed that the hospital's clinical leaders might need to tighten their management of shift handovers.
The ST1 doctor immediately went to see his consultant and explained what had happened. He co-operated fully with the subsequent hospital investigation, apologising for his part in what went wrong. This insight counted in his favour and while he was reprimanded, the ST1 was allowed to continue in his post. The investigation recognised that the trust's procedures were inadequate and a new handover protocol was implemented, including a checklist to ensure outstanding test results were properly noted and the responsibility assigned. The patient eventually recovered and the hospital formally apologised for the failings which had occurred during his care.
This article originally appeared in the printed edition of wardround April 2014 entitled "A message goes astray".
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