A member of care home staff walks around a garden with their arm around the shoulders of an older person.

Local integrated investigation pilot 2: Incorrect patient details on handover notes


The national investigation

This investigation is the second part of a pilot programme which aims to evaluate HSIB's ability to carry out effective locality-based investigations. Following evaluation, we'll consider this model for implementation more widely by HSIB.

The pilot was undertaken to understand whether, using the experience gained from the maternity programme, the national investigation model can be adapted to investigate individual incidents which could develop local trust/organisation and system learning. This may further HSIB’s contribution to improvements in patient safety at local, regional and national levels.

Scope of the pilot

HSIB engaged with several acute hospitals and ambulance trusts who were asked to refer incidents that involved cross-boundary care (for example, ambulance services, acute hospitals, and primary care services).

Following referral, HSIB reviewed the incidents to consider whether to launch an investigation as part of this pilot. The HSIB investigation does not replace any trust requirements for their own local investigations.

HSIB also engaged with several internal and external stakeholders to support delivery of the pilot.

Outputs of the pilot

HSIB intends to publish up to four local investigation reports and a subsequent evaluation of the pilot. The reports will be published on this page as they are completed. The first report was published in November 2021 and subsequent reports will be published in early 2022.

Each investigation report presents findings from a single investigation. The associated safety recommendations are made specifically to the organisations involved in the investigation. Organisations are anonymised.

The reports also identify safety risks that might be addressed by future national investigation by HSIB.

Reference event

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.

Investigation summary

The investigation focused on the key communication points in Mrs E’s care pathway, at which patient identification details were transferred during pre-hospital, admission and inpatient care.

This included detailed investigation into:

  • interaction between healthcare providers and handover of patient identification details
  • the systems and processes used by each healthcare provider for patient identification
  • the local healthcare providers’ guidance, policy, and initiatives in support of patient identification.