Case file: Advice

It's all in a good handover

Good clinical handovers are vital when transferring the care of a patient between different services. This case study examines what can happen when important information is missed during the handover process.

  • Date: 03 June 2024
  • |
  • 4 minute read


Dr D, a junior doctor, is asked by their clinical lead to provide a statement for an internal hospital investigation.

Dr D was involved in the care of an elderly female patient who had suffered a minor head injury. When the patient presented in the Emergency Department it was noted that she was on a direct oral anticoagulant (DOAC) having had a deep vein thrombosis (DVT) the previous month.

Following a multi-disciplinary team (MDT) review a plan was agreed to temporarily stop the DOAC for two weeks, after which this was to be restarted. This information was recorded in the patient’s medical record, and she was admitted to the ward overnight for observation.

Dr D was working on the ward the following morning when it was agreed the patient could be discharged. Dr D completed the patient’s discharge letter to her GP; however, they did not include any reference to her DOAC medication or the instruction that this was to be restarted in two weeks. The GP subsequently reviewed the discharge letter and carried out a medicine reconciliation, removing the DOAC from the patient’s repeat medications. The patient suffered a pulmonary embolism six weeks later.


Dr D initially contacted MDDUS’ advice line to discuss the case and seek assistance with writing a report for the local investigation into the clinical incident.  

On initial discussion, Dr D reported the time pressure they were under when completing the patient’s discharge summary, which may have resulted in them missing the entry in the patient’s medical record regarding the DOAC. Dr D explained that the ward pharmacist had also failed to notice the change to the patient’s medication.

The adviser empathised with Dr D. They discussed the importance of a good clinical handover where responsibility for patientcare is being transferred between members of the same team, different teams, or on this occasion, different services. It is vital that clear written communication is provided between secondary and primary care to maintain continuity of care and patient safety.

Dr D stated that discharge planning could be rushed and carried out in a busy area of the ward. The adviser highlighted that this process should ideally be undertaken in a quiet area, away from distractions, with sufficient time set aside for doing so.  

They also discussed the importance of making patients aware of any changes to their care. On this occasion, Dr D explained that they did not believe the patient would have had the capacity to understand and retain the information in relation to their management plan if this had been explained to her by colleagues prior to discharge.

The adviser reminded Dr D that when a patient lacks the capacity to understand information about their healthcare, it is especially important to ensure family members or carers are involved, where appropriate, to ensure all decisions are made in the patient’s best interest. The patient should also be involved as far as possible and be given sufficient information in a format easily interpretable to them.   

The adviser directed Dr D to MDDUS’ medical advisory guide on writing a statement. They also advised Dr D on the value of reflecting on their usual process when completing discharge summaries and handing over patient care to a primary care colleague. The adviser asked Dr D to consider if there were any learning points or changes to their practice they could implement going forward.  

Dr D submitted both their factual statement and reflections to MDDUS for review. Dr D acknowledged that they omitted to include all the required information needed for the GP to continue to provide safe ongoing care to the patient. Dr D reflected that since the incident they looked for a quiet area of the ward when preparing discharge letters to reduce the potential for interruption.

Dr D also recognised the need to pay particular attention to checking patient records to establish if there have been any alterations to their medication during their admission.

Dr D informed the adviser that they had discussed the case and their learning with the clinical lead, who commended Dr D for their careful reflections on the error and for making changes to their practice.  


Clear communication is essential for the continuity of safe patient care. 
Consider your professional obligations when handing over or delegating the care of a patient to a colleague and follow your local procedures.  
Set aside time for discharge planning in a quiet area and follow any local structured handover template to ensure all relevant information is included. 
Involve patients, and their family/carers where appropriate, and other treating healthcare professionals in ongoing management plans.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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