The importance of appropriate handovers

Introduction

Care home staff and healthcare workers will be aware of the importance of handover of key patient information. This was brought sharply into focus in a recent Inquest where a conclusion of ‘unlawful killing’ was returned.

Background

P (a 69 year old man) died in his care home after choking on a sandwich provided by a carer, despite being prescribed a ‘soft food’ (pureed food) diet.

The Inquest heard that the day staff at the care home were aware of the requirement for a pureed food diet, but the night staff were unaware of this. There was evidence that P was given sandwiches by night carers on a number of occasions. Several entries for his (‘hard’) food were signed for in the care records by a staff member covering the shifts, who accepted at the Inquest that she had not read the entries before signing them.

Unlawful Killing

On 24 October 2019, P was given a sandwich and left in his room. Shortly afterwards he was found to be choking. An ambulance was called and paramedics attempted to provide emergency advice to the care staff by telephone. Upon arrival, the ambulance crew tried to resuscitate P but were unsuccessful. A cause of death was given as acute upper airway obstruction (choking), with a background of dementia.

The death was reported to the Coroner, the Police, Care Quality Commission (‘CQC’) and the Nursing and Midwifery Council (‘NMC’). 

The Inquest heard that the care staff member was unaware that P should not have been given sandwiches. Submissions were made to the coroner regarding a conclusion of ‘unlawful killing’. 

The elements to establish unlawful killing in an Inquest setting are as follows:

• there was a duty of care owed;
• there had been a breach of that duty of care;
• the breach of duty gave rise to an obvious and serious risk of death;
• it was also reasonably foreseeable that the breach of that duty gave rise to an obvious risk of death;
• the breach of duty had caused the death; and
• the circumstances of the breach were truly exceptionally bad and so reprehensible as to justify a conclusion that amounted to gross negligence and required criminal sanction.

The coroner found that all the elements of the test of gross negligence manslaughter were made out by the actions of the carer. He therefore concluded that P had been unlawfully killed and recorded a conclusion of ‘unlawful killing’.

Analysis

A conclusion of ‘unlawful killing’ is a relatively rare occurrence at an Inquest. This is because of the stringent legal test that needs to be met for such a finding and conclusion to be made.

In this case there was a serious and repeated error (of not handing over the dietary information) that directly caused the death. Given that P was assessed as being at risk of choking on solid food and had been prescribed a pureed diet, it was reasonably foreseeable that he was at risk of choking and death. A safe system of handover and a responsibility to communicate this information properly as between day staff and night staff would likely have prevented this from occurring.

Handovers

The importance of appropriate written and verbal handovers cannot be overstated when it comes to providing patient care, particularly in an elderly care home setting, where patients are vulnerable. Issues such as dementia, which are commonplace in such settings, contribute significantly to this vulnerability and means that care staff need to be extra vigilant about following care plans, risk assessments and handing over important information, in order to keep patients safe.

Conclusion

This tragic death serves as a salutary reminder of the importance of handovers between healthcare staff. While the outcome of this Inquest turns on its own facts, in particular that the patient was given solid food in error on several occasions (and importantly, no precedent is set for future inquests), care home staff and healthcare workers should be reminded of the importance of care plans and risks assessments generally and of the vital importance of handovers.