Archi Johnson
26 Jul 2022 · Coroner Alison Longhorn · Exeter and Greater Devon
This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. incomplete risk assessment information
“Evidence was heard regarding the manner in which information crucial to the formulation of risk assessments was recorded and shared”
2. missing prior suicide attempt
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
3. lack of awareness of prior incident
“Those responsible for his care accepted that the above incident was one of which they would have wanted to have knowledge”
4. inadequate risk mitigation
“The absence of that information may have affected the subsequent decisions made regarding the setting of risk level, observation level and removal of potentially dangerous ligature items”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“lack of record keeping on the Ri O of (i) Risk Assessments and details of those persons making the assessments.”
This report
“Two types of risk assessments were completed, with no system to ensure that important information is present on both;”
Closely relatedConfidence 0.90 · high
This report
“The previous incident in which [the deceased] had attempted to take his own life in very similar circumstances on the ward was not clearly entered on the risk assessments used by staff and therefore not known to a number of those responsible for his care”
Later report
“At least one member of staff was unaware that [the deceased] had described himself to staff in May 2020 as looking for an opportunity to take his own life if it arose”
Responses
2022-0231-Response-from-Devon-Partnership-Trust-Care.pdf ↗· Devon Partnership NHS Trust
Stated action
“The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”