James Fitzpatrick

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.