6 December 2000

Handover - It's Important - Coroner's Decision

Having adequate time to perform handover at the beginning and end of each nursing shift is an extremely important element in ensuring patient safety.

Coroner identifies adequate handover time as a crucial issue!

Arising from an inquest into the death of a patient at a private hospital, the Coroner has made the following recommendations:

1. "That before the commencement or cessation of any nursing shift, there be provision for handover between the outgoing and incoming nursing personnel so as to provide sufficient time for the reading of all patient charts, the clarification of any patient care issues from off-going staff, the meeting with colleagues, with professional colleagues, so as to organise priorities of the shift, orientation of new staff members including agency or casual staff to the unit and patients, completion of all necessary patient documentation and reports and the determining of ongoing positioning, placement or transfer or patients.
   
2. That in the event of an adverse change in the health condition of a patient, the next of kin be advised thereof with all due expedition."

It should be noted that in making the above recommendation the Coroner did state "there is place at the … Private Hospital a regimen which is sufficient in a , to a very large degree, which if implemented supervised and enforced, capable of preventing a repetition of a death such as the subject of these proceedings."

This suggests that simply having a 'process' or 'procedure' on paper is insufficient if it is not properly implemented, supervised and enforced. For example, requiring nurses to perform handover but not allowing sufficient time for it to occur, or not ensuring that it occurs properly, will not satisfies the Coroner's recommendations.

While the Coroner's recommendations are not in themselves legally enforceable, failure to acknowledge or act on such publicly-made recommendations could almost certainly be raised in future inquests or other hearings.

The QNU will not hesitate to use the failure by an employer to provide adequate handover time in accordance with the above recommendations in any relevant proceedings.