Adam Carter

1. 1. record keeping

   “The concern relates to record keeping.”

2. 2. risk documentation

   “He did not feel that these risks were documented or clearly formulated in the medical notes.”

3. 3. inadequate leave documentation

   “Hestated that there was very little detail in the documentation as regards [the deceased]'s use of his leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave.”

4. 4. missing clinical assessment record

   “He was unable to find a record of an assessment of [the deceased]'s clinical state b nursing staff immediately before the period of escorted ground leave on 10 September 2017 as required by trust policy”

5. 5. incomplete leave authorization

   “Hecould not find a copy of the Leave Authorisation that granted [the deceased] leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence.”

6. 6. handover reliance on verbal information

   “Staff taking over the care of a patient such as [the deceased] ought not to have to rely on the verbal information provided to them at a handover of that patient's care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant [name redacted], and why he or she has been granted leave.”

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