Patient death led to new doctor handover policy

A NEW procedure for handing over patient care from one consultant to another is to be introduced at the Mater hospital, Dublin.

The change was recommended by an investigation into the death of a patient and was welcomed yesterday by his family.

Colin Evans (26), from Donaghmede, Dublin, had a congenital heart condition and was admitted to the hospital in 2005 with an infection.

As a result of the infection he had an operation to change his pacemaker.

However, following the operation he had an adverse reaction to antibiotics.

He died of cardiac arrhythmia with a second factor of adverse drug reaction.

An independent review at the hospital followed a complaint by the Evans family in 2006.

It concluded that there was a systems failure at the hospital and recommended that a clinical handover system be introduced.

Colin Evans’s consultant had been on leave following his operation and there had been no formal procedure for handing his care over to another consultant.

Under the new system to be introduced by the hospital next Wednesday, when a consultant goes on holidays, patient care is to be formally handed over using a form signed by both medical teams.

“We are delighted to have achieved something to safeguard patient lives in the future and to prevent other families going through the agony we have,” said Barry Evans, brother of Colin yesterday.

The new system is being dedicated to Colin’s memory.

“Colin made lived life to the full and made his life count. We wanted to make his death count,” Barry Evans said.

It is understood that this is the first time such a protocol has been introduced in Ireland.

The Evans family is appealing for it to be introduced at all hospitals around the country.

“You take it for granted that there is a proper handover system, but there is often a lot of assumption and verbal agreement,” Barry Evans said.

In a statement the Mater hospital said it had “worked closely with the Evans family during the various stages of the complaints process.

“This process led to a number of recommendations, one of which was the development of an inpatient clinical handover to a new consultant policy. There was open communication with the family in drawing up this policy,” it added.