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.

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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.

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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

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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.

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.

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.

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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.

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.

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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.

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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.