Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of written observation protocol for child and adolescent mental health unit
The earlier warning
Samiyo Farah · 30 Apr 2014 · Lisa Hashmi, Manchester (North)
“Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues.”
judiciary.uk/prevention-of-future-death-reports/samiyo-farah
What was promised
A published response was found, but no specific action could be extracted with a verified quote.
What recurred
- 21 May 2014 · Mark Bartholomew · Simon Nelson
- 2 Feb 2015 · Kimberley Lindfield · Nigel Meadows · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · Samiyo Farah · 30 Apr 2014
“Observation protocol - there is no national guidance/policy on the observation of children and adolescents within specialist mental health units. At present, clinicians are forced to adopt/adapt policies applied to adults with mental health issues.”
Later · Kimberley Lindfield · 2 Feb 2015
“Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient's mental state and/or self harrm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded)”
What happened next
No web check of the stated actions has been published for this chain.