Andrew Goldstraw
21 Feb 2020 · Coroner Simon Burge · Hampshire (Central)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. inadequate electronic health record system
“A. The computer system used by CNWL is known as SystmOne. Healthcare staff working on Reception when Mr [name redacted] first arrived at the prison had access to his previous medical notes and history (around 240 pages in all) stored on SystmOne. The records contained numerous references to suicidal ideation and previous attempts at deliberate self-harm. Mr [name redacted] had attempted to take his own life on several previous occasions, the most recent of which was only three months prior to his arrival at”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“There are issues of poor communication which need to be addressed. I acknowledge that even the most detailed communication in this instance may not have averted Mr McAndrews' actions and subsequent death.”
This report
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Identical hazardConfidence 0.90 · high
Earlier report
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'.”
This report
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”