James Fitzpatrick

Corporate Office   
Sentinel House  
Nuffield Industrial Estate  
2 Nuffield Road  
Poole, Dorset  
BH17 0RB  

1st April 2026  

Dear Mrs Griffin,   

Re: Regulation 28 Report following the inquest touching on the death of James 
Fitzpatrick 

I acknowledge receipt of the Regulation 28 Report issued to Dorset HealthCare 
University NHS Foundation Trust on 12th February 2026, following the inquest 
touching on the death of James Fitzpatrick.  

Firstly, I want to express my sorrow about the death of Mr Fizpatrick and to reiterate 
our condolences to his family and loved ones. 

In your regulation 28 letter you identified six areas of concerns that were associated 
with handover processes and you highlighted there was no written local and national 
guidance on the handover of a patient’s care. In response to your six identified areas 
of concern highlighted, please see our responses below. 

1.  There is a lack of written national guidance on how handovers between 

Doctors, Nurses and support staff should be undertaken either when a patient 
is moved between wards or hospitals, or when there is the handover to staff 
starting a shift who will be taking over the care of the person. Whilst it is 
acknowledged that each Trust has different policies and procedures in place, 
there is no generic national guidance to assist in ensuring relevant, pertinent 
and critical information is passed on to those who will be caring for the patient.  

Trust Response:  
Following the concerns raised, we undertook a further review to determine 
whether any national guidance was in development.  At present, we are not 
aware of any proposed updates or new guidance documents regarding 
community and mental health handover processes. We await the response 
from the National Bodies identified in your Regulation 28 report (NICE, GMC, 

 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
  
  
 
 
 
  
  
 
 
 
 
 NMC), and any guidance that is issued in this area.  However, in the meantime 
we have reviewed our own local arrangements and our additional action in 
relation to this is set out in section 3 below. 

2.  Evidence was provided that national guidance currently exists in England and 
Wales for handovers relating to emergency care in acute hospitals, however 
there is no other guidance for other healthcare settings as to what a handover 
should include or how it should be undertaken. 

Trust Response:   
A further review was undertaken and the NICE guidance reviewed again, which 
confirmed that there remains no current guidance specifically regarding 
community and mental health inpatient areas. We await the response from the 
National Bodies identified in your Regulation 28 report (NICE, GMC, NMC), and 
any guidance that is issued in this area.   However, in the meantime we have 
reviewed our own local arrangements and our additional action in relation to 
this is set out in section 3 below. 

3.  Within DHUFT there is a lack of written guidance or policy as to how handovers 

should be undertaken and recorded by those working within the Trust. 

Trust Response: 
The Trust acknowledges there is no specific policy/guidance around handovers 
currently in place. Discussions have taken place with senior leads across both 
physical and mental health inpatient services in respect of this following the 
inquest. 

The current position is that: 

•  our community hospitals use SystemOne, which generates an electronic 
handover document based on core principles of good handover practice 

•  Mental health services use RiO, which does not currently support 

electronic handover document extraction, leading to continued reliance on 
paper processes 

We are committed to ensuring that the development and implementation of the 
new pan-Dorset electronic health record in 2028 prioritises a robust, accurate, 
and live handover function to support safe and consistent practice across all 
services.  

In the interim, we have commenced development of guidance for staff 
regarding the format of handovers on inpatient units. This is based on SBAR 
(Situation, Background, Assessment, Recommendation) principles. This is 
currently being taken through our internal governance process.  If national 
guidance becomes available, we will review and align our local guidance 
accordingly.  

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 Alongside this immediate action to develop this guidance we have adopted a 
focus on handovers as a Trust Quality Priority for 2026/27. As part of this work, 
the first action is to scope the handover processes across all mental health 
inpatient units by June 2026. This will allow us to understand current 
approaches, the reasoning behind them, and what changes are required in light 
of the learning from this inquest whilst we await the new electronic health 
record. Establishing the Quality Priority for “Improving Inpatient and Transfer of 
Care Handovers”, means that audits of any incidents relating to concerns 
regarding handover processes will be reviewed and reported through the 
Directorate Management Groups for oversight and assurance. The auditing 
processes will be undertaken between June 2026 and March 2027. 

4.  Two weeks prior to his death, Jim was moved to another ward within Alderney 
Hospital. There was a verbal handover undertaken which was recorded in the 
electronic patient records. No written handover was provided. The patient 
records referred to him being a “high risk of choking” and “on an unofficial soft 
diet”. This information was not true and was not recorded anywhere else in his 
records or risk assessments.  

Trust Response:  
We recognise that handover practices vary across mental health inpatient 
areas, with some relying on verbal handover or a combination of verbal and 
paper processes. These variations often reflect the nature of the patient group, 
some of whom may remain in services for extended periods. 

However, the actions noted in section 3 above will introduce consistent 
guidance across the trust, and the work described as part of our Trust Quality 
Priorities for 2026/27 will support audit of this specifically in our mental health 
inpatient settings. This will allow us to understand current approaches, the 
reasoning behind them, and whether changes are required in light of the 
learning from this inquest whilst we await the new electronic health record. 

5.  Further evidence was given that at the time of Jim’s death there were a number 
of agency workers at Alderney Hospital, and they would rely on information 
provided to them at the start of their shift during the handover as they would not 
have time to go through each patient’s records to appraise themselves of the 
patient’s history and risks. A daily written handover sheet was provided at the 
beginning of each shift which would be updated during the day, however from 
the daily handover sheet provided to the Court for the day of Jim’s death, 
pertinent general information about Jim was missing from that handover sheet.   

Trust Response:  
As noted above under points 3 and 4, and as part of the wider review 
described, we are taking action to support greater consistency and reduce the 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
  
 
 risk of omissions, through developing a guidance document based on SBAR 
(Situation, Background, Assessment, Recommendation) principles. If national 
guidance becomes available, we will review and align our local guidance 
accordingly.  

Progress will be monitored quarterly through Dorset HealthCare’s Quality 
Governance Group. This will ensure there is appropriate governance and 
oversight at a senior level within the Trust. 

6.  The lack of written local and national guidance on the handover of a patient’s 
care creates a risk that incorrect or incomplete information can be passed to 
those caring for an individual which may impact upon the patient’s care and 
may lead to a future death.  

Trust Response: 
The actions identified above that are now underway seek to address the 
concerns identified and will strengthen local handover processes. Oversight will 
continue through the Quality Governance Group, supported by quarterly audits 
reviewing incidents across all inpatient wards where handover may have been 
a contributing factor. 

I hope that this response, and the actions and improvements we have commenced, 
provide assurance that the Trust is committed to learning from this inquest and to 
strengthening the safety and reliability of handover processes across our services. 
We will continue to monitor any developments in national guidance and ensure our 
Trust Board remains fully sighted on progress, including the role of the future 
electronic health record in reducing gaps, inaccuracies and omissions.  

Our thoughts remain with Mr Fitzpatrick’s family following their loss. We hope that 
the steps we are taking demonstrate our commitment to learning, improvement and 
the overall safety and care of our patients.  

Yours sincerely  

Chief Executive

25 March 2026 

Rachael C Griffin 

HM Senior Coroner for Dorset 

The Coroner's Office for the County of Dorset 

Civic Centre 

Bourne Avenue 

Bournemouth  

BH2 6DY 

Dear Rachael 

I am writing in response to your letter of 12 February 2026 enclosing your report into the death of 
James Fitzpatrick. I am sorry to hear of the circumstances surrounding Mr Fitzpatrick’s death, and I 
extend my condolences to his family and friends. 

I appreciate the opportunity to review your report and respond to the concerns that you raise. I am 
responding as the Medical Director and Director of Education and Standards at the General Medical 
Council, and I have engaged with the matters of concern raised that are within our remit as the 
professional regulator of doctors, physician associates (PAs) and anaesthesia associates (AAs) in the 
UK. 

I have noted your concerns around a lack of national written guidance on how handovers between 
doctors, nurses and support staff should be undertaken either when a patient is moved between 
wards or hospitals, or when there is the handover to staff starting a shift who will be taking over the 
care of the patient. 

We set a number of professional standards that are relevant to the concerns you’ve raised in your 
report and we regularly work with others across the system to raise awareness of the standards and 
support the professionals on our register to implement them. 

In preparing our response, we met with the Nursing and Midwifery Council (NMC) to discuss 
alignment across our respective pieces of guidance and to explore opportunities for future 
collaborative working to develop some joint messaging highlighting the expected standards for 
communication within and across the multi-disciplinary team.  

The GMC is a charity registered in England and Wales (1089278) and Scotland (SC037750). 
You are welcome to contact us in Welsh. We will respond in Welsh, without this causing additional delay. 

 
 
 
 
 
 Our role and the role of our guidance 

Our role 

We work with doctors, PAs, AAs, patients and other stakeholders to support good, safe patient care 
across the UK. We set the standards that our registrants and their educators need to meet, and help 
them achieve them. If there are concerns these standards may not be met, or that public confidence 
in doctors, PAs or AAs may be at risk, we can investigate and take action if needed. 

Our professional standards 

We set the values, knowledge, skills and behaviours expected of all doctors, PAs, and AAs registered 
with us when caring for patients and working with colleagues. Our core guidance on professional 
standards, Good medical practice, and the more detailed guidance which supports it, form the 
professional standards we expect all doctors, PAs and AAs to follow.  

We do not set clinical standards or give clinical advice to our registrants. This is the role of a wide 
range of other bodies, such as the National Institute for Health and Care Excellence (NICE), 
government health departments and the medical royal colleges. I can see that you have sent your 
report to NICE.  

The development of Good medical practice (2024) and continuity of patient care 

We recently completed a review of Good medical practice and the latest version (effective from 30 
January 2024) was developed following an extensive public consultation process, involving members 
of the professions, the public, patients and other stakeholders. Analysis of the responses revealed 
that team working and continuity of care were priority themes and we strengthened the guidance in 
several areas to reflect this. 

We added an introductory paragraph to the standards around contributing to the continuity of care 
for all patients. Paragraph 65 says; 

Continuity of care is important for all patients, but especially those who may struggle to navigate 
their healthcare journey or advocate for themselves. Continuity is particularly important when care is 
shared between teams, between different members of the same team, or when patients are 
transferred between care providers. 

Paragraph 65 expressly refers to patients who may struggle to navigate their journey, such as the 
elderly, the vulnerable, those with multiple illnesses and those who lack capacity. We also refer to 
sharing reasonable adjustments and communication support preferences with others involved in 
their care, within and across teams as required. We make clear that registrants must be confident 
that information necessary for ongoing care of the patient has been shared, for example, before a 
registrant goes off duty, delegates care or refers the patient to another health or social care 
provider.  

gmc-uk.org 

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 We also strengthened the wording of our expectations around delegating safely and appropriately at 
paragraphs 66 and 67. We expect the professional delegating care of the patient to be confident that 
the person they are delegating to has the necessary knowledge, skills and training to carry out the 
task. Clear instructions must be given, as well as encouragement to ask questions and seek support 
or supervision if it’s needed. And the professional receiving a delegated task must be confident that 
they have the necessary knowledge, skills and training to undertake it; if they are unsure, they must 
prioritise patient safety and seek help. 

Our guidance on record keeping 

Good medical practice sets out our expectations of registrants regarding recording their work clearly, 
accurately, and legibly at paragraphs 69 and 70.  

More detailed guidance on handover 

Our Leadership and management guidance expands on what we say in Good medical practice, and 
goes into further detail regarding communication and team working. Within this guidance we set 
standards which relate to all medical professionals registered with us, and we also set standards for 
those medical professionals with extra responsibilities.  

Paragraph 12 of the guidance refers to all medical professionals. It says that medical professionals 
should not assume that another team member will pass on the information needed for patient care. 
They should check if they are unclear about the responsibility for communicating information, 
including during handover, to members of the healthcare team, other services involved in providing 
care and patients and those close to them. 

Our review of our guidance on Leadership and management and Raising concerns 

We have recently conducted a public consultation on these two pieces of guidance, and we are in 
the process of analysing the results. We intend to publish a report on the findings of the consultation 
later this year and will go on to develop an updated version of the guidance. We will consider the 
concerns raised in your report as part of this review process. 

As mentioned above, paragraph 12 of Leadership and management already makes explicit reference 
to handover. However, we received feedback during the consultation process that there a common 
misperception that the standards we set in this guidance apply only to those in specific management 
or leadership roles. One of our key objectives when we launch the updated guidance, therefore, will 
be to emphasise the importance and relevance of the standards in the guidance to all registrants, 
not just those in management or leadership roles. 

Also of note, paragraph 15 currently sets the expectation that registrants with extra responsibilities 
must be satisfied that systems are in place to communicate information about patient care. When 
we look at redrafting this duty, we will aim to be more explicit that the duty extends to ensuring that 

gmc-uk.org 

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 all relevant, pertinent and critical information about a patient is shared between all the healthcare 
professionals involved in their care, especially when care is passing from one team to another. 

I have included an annex to this response which sets out the full wording of the all the standards I 
have referred to, and also some additional standards from the current version of Leadership and 
management around communication with and between teams (paragraphs 10, 11, 13 and 14). 

The work we do to support implementation of the professional standards 

Our Outreach teams across the UK regularly give talks and run workshops on the implementation of 
our guidance to our registrants. These workshops will often highlight the importance of 
communication, teamwork, ensuring effective information sharing and prioritising patient safety.  

Implicitly, within most workshops we deliver we include the messaging that doctors should 
communicate well, work collaboratively with colleagues, contribute to a team, reflect on their own 
performance and document their actions/notes clearly and accurately. 

Whilst we do not deliver a workshop which specifically focuses on handovers and continuity of 
patient care, we have a case study we use that covers themes within Good medical practice which 
support continuity of care and safe delegation.   

Next steps 

We will continue to liaise with the NMC to identify any areas where we can work in partnership to 
raise awareness of the expected standards regarding communication and collaboration across the 
professions we regulate. One of the areas in which we have already done this is in maternity care, 
where we have worked with the NMC to develop resources to support professionals working in this 
area.  

We will explore opportunities to promote our expectations regarding handovers, continuity of care, 
team working and communication with our Outreach team as we look to promote and implement 
our updated guidance on Leadership and management and Raising concerns. 

I hope that my response has provided you with reassurance that we set professional standards which 
speak to the concerns you have raised, and that we will continue to emphasise the importance of 
communication and teamwork around patient safety in our messaging as we progress with our 
future work in developing our professional standards. 

Yours sincerely, 

Medical Director and Director of Education and Standards 

gmc-uk.org 

4 

 
 
 
 Annex  

Paragraph 65 of Good medical practice 

a. You must promptly share all relevant information about patients (including any reasonable 
adjustments and communication support preferences) with others involved in their care, within and 
across teams, as required. 

b. You must share information with patients about: 

i. 
ii. 
iii. 

the progress of their care 
who is responsible for which aspect of their care 
the name of the lead clinician or team with overall responsibility for their care 

c. You must be confident that information necessary for ongoing care has been shared:  

i. 
ii. 
iii. 

before you go off duty 
before you delegate care, or 
before you refer the patient to another health or social care provider.  

d. You must check, where practical, that a named clinician or team has taken over responsibility  
when your role in a patient’s care has ended. 

Paragraph 10 of Leadership and Management 

Communication within and between teams  

Multidisciplinary teams can bring benefits to patient care when communication is timely and 
relevant, but problems can arise when communication is poor or responsibilities are unclear. 

Paragraph 11 of Leadership and Management 

All medical professionals  

You must make sure that you communicate relevant information clearly to:  

a. colleagues in your team  

b. colleagues in other services with which you work 

c. patients and those close to them in a way that they can understand, including who to contact if 
they have questions or concerns.  

This is particularly important when patient care is shared between teams 

gmc-uk.org 

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 Paragraph 13 of Leadership and Management 

All medical professionals  

You should encourage team members to cooperate and communicate effectively with each other and 
other teams or colleagues with whom they work. If you identify problems arising from poor 
communication or unclear responsibilities within or between teams, you should take action to deal 
with them 

Paragraph 14 of Leadership and Management 

Medical professionals with extra responsibilities  

You must provide necessary and timely information to those you manage so they can carry out their 
roles effectively. You should also pass on any relevant information to senior managers and make sure 
that arrangements are in place for relevant information to be passed on to the team promptly. 

Paragraph 15 of Leadership and Management 

Medical professionals with extra responsibilities  

You must be satisfied that systems are in place to communicate information about patient care. 

Paragraph 69 of Good medical practice 

You must make sure that formal records of your work (including patients’ records) are clear, 
accurate, contemporaneous and legible. 

Paragraph 70 of Good medical practice 

You should take a proportionate approach to the level of detail but patients’ records should usually 
include: 

a relevant clinical findings 

b drugs, investigations or treatments proposed, provided or prescribed 

c the information shared with patients 

d concerns or preferences expressed by the patient that might be relevant to their ongoing care, and 
whether these were addressed 

e information about any reasonable adjustments and communication support preferences 

f decisions made, actions agreed (including decisions to take no action) and when/whether decisions 
should be reviewed  

g who is creating the record and when. 

gmc-uk.org 

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 Paragraph 20 of Good medical practice 

 You must give priority to patients based on their clinical need if these decisions are within your 
power. If inadequate resources, policies, or systems prevent you from doing this – and patient safety 
or dignity may be seriously compromised as a result – you must follow the guidance in paragraph 75 

Paragraph 45 of Good medical practice 

You must be open and honest with patients if things go wrong. If a patient under your care has 
suffered harm or distress, you must follow our guidance on Openness and honesty when things go 
wrong: the professional duty of candour, and you should:  

a put matters right, if possible 

b apologise (apologising does not, of itself, mean that you are admitting legal liability for what’s 
happened) 

c explain fully and promptly what has happened and the likely short-term and long-term effects 

d report the incident in line with your organisation’s policy so it can be reviewed or investigated as 
appropriate – and lessons can be learnt and patients protected from harm in the future. 

Paragraph 72 of Good medical practice 

You should be familiar with, and use, the clinical governance and risk management structures and 
processes in any organisation that you work for or are contracted to. 

Paragraph 73 of Good medical practice 

To help keep patients safe you must: 

a contribute to confidential inquiries 

b contribute to adverse event recognition 

c report adverse incidents involving medical devices (including software, diagnostic tests, and digital 
tools) that put the safety of a patient or another person at risk, or have the potential to do so  

d contribute to incident reviews and/or investigations 

e report suspected adverse drug reactions 

f respond to requests from organisations monitoring public health.  

When providing information for these purposes you must follow our guidance on Confidentiality: 
good practice in handling patient information.  

gmc-uk.org 

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 Paragraph 75 of Good medical practice 

You must act promptly if you think that patient safety or dignity is, or may be, seriously 
compromised. 

a If a patient is not receiving basic care to meet their needs, you must act to make sure the patient is 
cared for as soon as possible, for example by asking someone who delivers basic care to attend to the 
patient straight away.  

b If patients are at risk because of inadequate premises, equipment or other resources, policies or 
systems, you should first protect patients and put the matter right if that’s possible. Then you must 
raise your concern in line with your workplace policy and our more detailed guidance on Raising and 
acting on concerns about patient safety. 

c If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, 
you must ask for advice from a colleague, your defence body, or us. If you are still concerned, you 
must report this, in line with your workplace policy and our more detailed guidance on Raising and 
acting on concerns about patient safety. 

Paragraph 76 of Good medical practice 

If you have a formal leadership or management role, you must take active steps to create an 
environment in which people can talk about errors and concerns safely. This includes making sure 
that any concerns raised with you are dealt with promptly and adequately, in line with your 
workplace policy and our more detailed guidance on Raising and acting on concerns about patient 
safety.  

gmc-uk.org 

8

2nd Floor 
2 Redman Place 
London 
E20 1JQ 
United Kingdom 

10 April 2026 

Rachel Griffin 
HM Coroner  
The Coroner's Office for the County of Dorset,  
Civic Centre,  
Bourne Avenue, 
Bournemouth  
BH2 6DY 

Dear Ms Griffin 

Re: Regulation 28 Prevention of Future Deaths Report (James Fitzpatrick) 

I write in response to your regulation 28 report dated 12 February 2026, regarding 
the very sad death of James Fitzpatrick. I would like to express my sincere 
condolences to James’s family.   

The patient safety leads at NICE have discussed the report and understand that your 
request is that we develop national guidance on how handovers between doctors, 
nurses and support staff should be undertaken, either when a patient is moved 
between wards or hospitals, or when there is a handover to staff starting a shift, who 
will be taking over the care of the person. 

We have carefully considered this request, and our conclusion is that further NICE 
guidance in this area would not add to the guidance already available from other 
organisations such as the Nursing and Midwifery Council (NMC) the General Medical 
Council (GMC) and NHS England and overseen by the Care Quality Commission 
(CQC). I have explained our reasoning for this below 

The report has highlighted a number of areas for concern which the patient safety 
leads have addressed. 

1.  There is a lack of written national guidance on how handovers between 

Doctors, Nurses and support staff should be undertaken either when a patient 
is moved between wards or hospitals, or when there is the handover to staff 
starting a shift who will be taking over the care of the person. 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 2.  There is no national guidance for non-acute healthcare settings as to what a 

handover should include or how it should be undertaken 

NICE has published limited guidance in this area. NICE guideline Emergency and 
acute medical care in over 16s: service delivery and organisation (NG94) covers 
organising and delivering emergency and acute medical care for people aged over 
16 in the community and in hospital, and recommends the use of structured 
handovers during transitions of care. The NICE quality standard Emergency and 
acute medical care in over 16s (QS174) states in quality statement 4 that ‘Adults 
admitted with a medical emergency have a structured patient handover during 
transitions of care’. However, these recommendations do not quite apply to the 
circumstances of this report  

Other organisations however do have broad guidance on handover that is not setting 
specific. Both the NMC and the GMC place emphasis on good communication 
between practitioners and with patients, particularly at the time of patient transfer or 
handover. The NMC Code of Conduct states that practitioners should ‘Keep clear 
and accurate records relevant to your practice’; ‘complete records at the time or as 
soon as possible after an event’; and ‘Work in partnership with people to make sure 
you deliver care effectively”. 

These records include accurate handover, both oral and written. Standard 8.2 of the 
NMC code states that practitioners must ‘maintain effective communication with 
colleagues’ and 8.6 ‘share information to identify and reduce risk’.  

In ‘Good Medical Practice’ the GMC has detailed guidance on continuity of care 
(paragraph 65) and on delegating safely and appropriately (paragraphs 66-68); the 
GMC outlines what medical staff must do to work safely in the interest of patients 
during patient handover.  

In addition, NHS England has published Safe Communication: A guide to improving 
transfers of care and handover (NHS England, 2015), which sets out what good 
handover must achieve and how organisations should design it.  

These resources, and others, recommend the use of structured communication 
tools, standardisation of the format of handover and the minimum information 
required, the use of documentation to support verbal handover and the roles and 
responsibilities of practitioners during handover. 

We believe that detailed specific guidance for every individual healthcare facility on 
patient handover would be very challenging for a central organisation to produce and 
would not be well adapted to the local setting and context. Instead, each 
organisation should produce local, relevant guidance based on the resources 
outlined above.   

3.  Within DHUFT there is a lack of written guidance or policy as to how 

handovers should be undertaken and recorded 

This area of concern is for DHUFT to respond to.  

                                                                                                                                 Page | 2 

 
 
 
 
 
  
 
 
 
 
 
 
 4.  In a previous transfer, incorrect information was handed over about the 

person concerned 

This area of concern is for the NMC to respond to.  

5.  Staff relied on information provided to them at the start of their shift during the 
handover and a daily written handover sheet, provided at the beginning of 
each shift and updated during the day 

I have addressed this point above in explaining the various guidelines that exist for 
healthcare practitioners. We do not feel that an additional general recommendation 
to ‘ensure all pertinent information is included in written handover sheets’ is likely to 
prove effective.  

6.  The lack of written local and national guidance on the handover of a patient’s 
care creates a risk that incorrect or incomplete information can be passed.  
As noted above, there is general guidance on this from the NMC, GMC and NHS 
England. In addition, the CQC sets out clear expectations for safe, effective clinical 
handover within its fundamental standards and regulatory framework. Therefore, it is 
unlikely that further NICE guidance would improve on this current guidance. 

I hope that the information above is helpful in explaining the guidance that exists and 
my rationale relating to further guidance in this area.  

I would like to reiterate my sincere condolences to James’s family.  

Yours sincerely, 

Chief Executive 

                                                                                                                                 Page | 3 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
        
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                                                                                                  Page | 4

From the Chief Executive and Registrar                                                                                                         

Rachael Clare Griffin 
Senior Coroner for the Coroner Area of Dorset 
The Coroner's Office for the Area of Dorset 
Civic Centre 
Bourne Avenue 
Bournemouth 
BH2 6DY 

2 April 2026 

Dear Rachael 

Regulation  28  Prevention  of  Future  Deaths  report  dated  12  February  2026  in 
relation to James (Jim) Fitzpatrick 

I would like to begin by offering my heartfelt condolences to Jim’s family  for their tragic 
loss. 

Your report identifies areas of concern relating to different aspects of handovers between 
doctors,  nurses  and  support  staff.  Our  vision  is  for  safe  and  effective  nursing  practice 
across the four countries of the UK and as Chief Executive and Registrar of the Nursing 
and Midwifery Council (NMC) I take these matters very seriously.  

I set out below details of the action we have taken following receipt of your report and 
further steps we are considering.  

Concerns arising from your report 

Your concerns relate to the evidence you heard in respect of communication, handover, 
record  keeping,  escalation  of  risk,  and  the  safe  transfer  of  responsibility  for  care. You 
highlight a lack of written national guidance on how handovers between doctors, nurses 
and support staff should be undertaken either when a patient is moved between wards or 
hospitals, or when there is the handover to staff starting a shift who will be taking over the 
care of the person. You point to the lack of generic national guidance to assist in ensuring 
relevant, pertinent and critical information is passed on to those who will be caring for the 
patient.  

We  recognise  that  this  creates  a  risk  that  incorrect  or  incomplete  information  can  be 
passed to those caring for an individual which may impact upon the patient’s care and 
may lead to a future death. 

                                                                                                                 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Our response 

While  we  recognise  the  concerns  raised,  we  consider  that  communication,  handover, 
record  keeping,  escalation  of  risk,  and  the  safe  transfer  of  responsibility  for  care  are 
already  addressed  adequately within  the  Nursing  and  Midwifery Council’s  professional 
standards, including The Code: Professional standards of practice and behaviour for 
nurses,  midwives  and  nursing  associates  and  the  Standards  of  proficiency  for 
registered nurses.  

We  do  believe  national  guidance  would  be  helpful  to  support  a  consistent  and 
collaborative approach to handovers across the wide range of organisations responsible 
for delivering and regulating care. 

The  Code  sets  clear  expectations  for  the  professionals  on  our  register  in  relation  to 
communication, teamwork, record keeping and patient safety. In particular: 

•  Section 7 requires registrants to communicate clearly, including taking reasonable 

steps to meet people’s communication needs and checking understanding 

•  Section  8  requires  registrants 

to  work  co-operatively,  maintain  effective 
communication with colleagues, keep colleagues informed when sharing care, and 
share information to identify and reduce risk 

•  Section  10  requires  registrants  to  keep  clear  and  accurate  records,  including 
recording  risks,  problems  and  actions  taken  so  that  colleagues  have  the 
information they need 

•  Section  16  requires  registrants  to  act  without  delay  if  there  is  a  risk  to  patient 
safety, including raising and escalating concerns where care or public protection 
may be compromised 

•  Section 17 requires registrants to take reasonable steps to protect people who are 

vulnerable or at risk from harm. 

These standards apply in all settings and when responsibility for care is transferred 
between professionals or teams. 

Our Standards of proficiency for registered nurses (2018) also set requirements relevant 
to safe handover, coordination of care and information sharing. In particular: 

•  Platform 1: Being an accountable professional requires nurses to understand and 
apply  legal,  regulatory  and  governance  requirements  (1.2),  communicate 
effectively (1.11), keep clear and accurate records (1.16), and act to minimise risks 
to health and safety (1.5) 

•  Platform  5:  Leading  and  managing  nursing  care  and  working  in  teams  requires 
nurses  to  work  effectively  within  teams  (5.4),  communicate  with  colleagues, 
supervise  and  coordinate  care  (5.5),  and  provide  constructive  feedback  and 
challenge where care may be unsafe (5.9) 

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 •  Platform 6: Improving safety and quality of care requires nurses to recognise risks 
to  safety  (6.2),  comply  with  frameworks  for  reporting  and  managing  risk  (6.3), 
identify hazards and take action (6.6), and learn from incidents and near misses 
(6.8) 

•  Platform  7:  Coordinating  care  requires  nurses  to  work  in  partnership  across 
services  (7.1),  understand  policy  and  organisational  processes  (7.2),  and 
coordinate care safely across settings, including during transitions and transfers 
(7.10). 

These proficiencies apply to all registered nurses at the point of registration and underpin 
practice across all care environments, including mental health inpatient settings. 

Taken together, the Code and the standards of proficiency establish clear professional 
expectations that information relevant to a person’s safety must be accurately recorded, 
communicated and handed over when responsibility for care changes, and that nurses 
must act where failures in communication may place people at risk. 

Where we identify concerns that a professional on our register may not have met these 
standards, we will investigate this. Where concerns relating to patient safety are made 
out, we will take such action as is appropriate to protect the public and uphold trust in 
the professions in line with our fitness to practise process. 

Where we receive evidence of any concerns that may be relevant to public safety but 
which fall outside of our regulatory remit, we may decide to refer matters to the police or 
other appropriate authorities for further investigation, particularly where there is 
evidence of a poor outcome. 

Actions we have taken in response to your report  

In respect of the concerns arising in your report, we have: 

•  Met with the General Medical Council to discuss whether there are any areas 

where we can align to strengthen our joint position on handovers and to explore 
opportunities for future collaborative working to develop some joint messaging 
highlighting the expected standards for communication within and across the 
multi-disciplinary team 

•  Taken steps to ensure that the concerns raised in your report have been shared 
with relevant teams within the NMC to assess whether we need to take any 
further steps in line with our usual processes 

•  We  have  shared  your report with  our Intelligence  Sharing  Hub  (ISH)  to  assess 
and  share  emerging  concerns  or  risks  identified  across  other  regulators  and 
patient safety organisations.  The report will be discussed at its next meeting. 

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 Conclusion 

Thank you for sharing the areas of concern with us, identified during your investigations. 
We will continue to reflect on these issues. 

Once again, I would like to offer my condolences to Jim’s family for their tragic loss. 

Yours sincerely 

Chief Executive and Registrar 

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