Local integrated investigation pilot 2: Incorrect patient details on handover

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.

The pilot published three investigations focused on cross-boundary and multi-agency safety events.

This is the second pilot investigation.

The other pilot investigations are:

• Pilot 1: Incorrect patient identification
• Pilot 3: Transfer of a patient with a stroke to emergency care

This investigation focused on the systems and procedures in place to help health and care staff to correctly identify patients. It explores how the incorrect identification of a patient can have an impact on their treatment. To do this it uses a real patient safety event involving a patient who was cared for by a nursing home, an Ambulance Trust and an Acute Trust (that is, a local hospital with an emergency department).

The safety event involved Mrs E, a woman aged 93 with dementia. Mrs E was taken by ambulance to her local emergency department (ED) after a fall in her nursing home. She was accompanied by an escort from the home. Incorrect patient details (date of birth and spelling of surname) were used to book Mrs E into the ED.

The ED staff were unable to find Mrs E’s details on the digital patient management systems available. A new patient record was created with the incorrect patient details. After having an X-ray in the radiology department, which confirmed that Mrs E did not have a fracture, she was discharged the same day.

The next day, after another fall in the nursing home, Mrs E was taken to the same ED by ambulance. She was booked in under the new patient record created the previous day, with the incorrect patient details. Mrs E had an X-ray which confirmed a fractured neck of femur (broken hip) and she was admitted to the hospital for surgery.

Mrs E had surgery the next day, during which the pathology department identified a problem with the accuracy of her personal identification information. Following surgery, Mrs E’s correct identification details were confirmed, and her past hospital notes were gathered. The two sets of patient records were merged.