Barry Harmer

1. 1. lack of robustness in internal investigations

   “the initial Incident Learning Huddle and subsequent Patient Safety Incident Investigation (PSII) undertaken in 2024 lacked robustness and did not appear to have been revisited in the light of the emerging family concerns and evolving evidence during the coronial investigation”

2. 2. inconsistent operation of daily Patient Flow Meetings

   “variable evidence as to the operation of the daily Patient Flow Meetings, during which patients requiring beds would be matched to availability based on individual needs”

3. 3. absence of face to face psychiatric review for community patients

   “[the deceased] had not had any face to face psychiatric review at any point during the time he was open to Oxford Health was not addressed in the PSII and it remains unclear how this can be escalated for immediate attention in the community”

4. 4. significant issue with bed availability for agreed care plans

   “bed availability as part of an agreed or prescribed care and treatment plan remains a significant issue”

5. 5. inconsistent understanding and communication between Trust teams and families

   “The broader issues of consistent understanding within and between Trust teams and with proactive communication with patients in the community and their families will remain of concern if they are not addressed in policy and training”

No published response was found on judiciary.uk.