Adam Withers

“1) It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient's condition are important for the purposes of”

“It was clear from the evidence that any note made in a patient's record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective. This is necessary to ensure that all notes are accurate and reliable. The evidence at the inquest revealed that at least one member of nursing staff made entries on [the deceased]' manuscript observation record after he had died, without marking the entries as retrospective.”

“At the inquest the number of nursing staff (Registered Nurses and Health Care Assistants) on duty on Elgar Ward was considered. It was apparent from the evidence that the nursing staff levels could result in patients on the ward being insufficiently supervised at meal times and staff stated in evidence that they did not always have time to read patients' notes as they should.”