Case file: Advice

The importance of a good handover in a secondary care setting

Comprehensive handovers are essential when working with complex patients. This case study reviews a complaint which arose following a patient death where a poor quality medical handover was cited as a contributory factor.

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


Dr H, a trainee in acute medicine, was contacted by the GMC following a complaint from a patient's sister.

Dr H had been asked to review the patient on a Friday afternoon, following the patient's recent admission to an orthopaedic ward with a fracture. The patient had a known uncommon cardiac condition.

Dr H assessed the patient and then spoke to the medical consultant. They agreed the patient would need careful monitoring of fluid balance and blood parameters over the weekend, with adjustments to their medications depending on the results. On leaving the ward, Dr H told a ward nurse that they had documented the plan in the notes.

Tragically, the patient died over the weekend following a significant deterioration in their condition. The Trust’s clinical incident investigation found that poor quality medical handover was a contributory factor in the patient’s death. 

In her complaint to the GMC, the patient's sister highlighted the concerns referred to in the local investigation, including the fact that Dr H's documentation of the plan in the patient’s notes was illegible and that Dr H did not appear to have verbally handed over the plan for monitoring any actions required, or when to escalate the patient's care. 

Dr H contacted MDDUS for advice.


A MDDUS adviser arranged to speak with Dr H about the case and the GMC process. Dr H accepted that their handwritten plan for the weekend was almost illegible. They also confirmed that their usual practice is to provide a verbal handover of complex patients to the on-call team, but this is not documented and they cannot recall if they did so in this case. They recognised it would have been essential to speak with the ward nurses to ensure they understood the monitoring the patient needed and when to escalate any concerns. 

The MDDUS adviser recommended that Dr H reflect on the case to identify learning needs and consider how these can be addressed. The adviser highlighted the GMC guidance regarding continuity of care and delegation.

Subsequently, Dr H attended courses on record keeping and working and communicating as part of a team, and they reflected on what they had learned. Dr H also participated in a review of the hospital process for weekend handovers. The group recommended the use of a structured electronic handover form to complement the verbal handover of complex patients. 

MDDUS submitted a detailed response to the GMC on behalf of Dr H. This included an account of Dr H's reflections on the case and learning. Dr H acknowledged how essential a good handover is to maintaining patient safety. They now always ensure when handing over that the recipient understands the information given and has the opportunity to ask questions.

The GMC ultimately concluded the investigation with no further action. The expert opinion found there were systemic issues contributing to the failure to identify the patient’s deterioration, and that while Dr H’s overall standard of care fell below the standard expected, it was not seriously below.

The GMC also acknowledged that Dr H had proactively identified learning points, undertaken focused learning and had changed their practice following this incident. 


  • Medical handover is a critical point in patient care. 
  •  Your documentation should be legible and provide a clear plan with specific parameters for intervention and escalation.
  • Always consider whether you also need to provide a verbal handover. These allow you to ensure your handover plan is understood and for any questions to be addressed. Verbal handovers should be documented wherever possible.
  • Handover should be provided in a structured way. Consider the use of a template.  

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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