Darren Turner

1. 1. inadequate care plan updates

   “Failures in Care Planning: specifically, a failure to appropriately up-date and document matters relating to [the deceased]'s Care Plan consistent with Trust policy. The last up-date to his Care Plan was 12 days prior to discharge.”

2. 2. inadequate electronic records

   “Failures in Documentation: in a number of acknowledged respects the electronic records were inadequate - and inconsistent with EPUT policy - with evidence of the 'cutting and pasting' of entries including [the deceased]'s initial 72-hour care plan containing details of another patient entirely.”

3. 3. inadequate risk assessment documentation

   “Failures in Risk Assessments: specifically, failures to appropriately up-date and document matters relating to [the deceased]'s risk assessment consistent with Trust policy. Relevant passive and active risk factors were not formally reflected in his documented risk assessments. Evidence from his Responsible Consultant [name redacted] and the discharging Psychiatrist confirmed that, had they been aware of a disclosure made by [the deceased] to his key worker/nurse prior to discharge, the Section 2 detention would not”

4. 4. failure to allocate care coordinator

   “Failure to allocate a Care Coordinator as required under the Care Programme Approach (CPA) and as mandated by EPUT policy. This failure (resulting from significant human error not detected by an insufficiently robust system and not therefore corrected prior to the death- and in respect of which no DATIX was ever raised) was a feature that contributed to the serious failure in discharge planning in this case.”

5. 5. inadequate communication with family

   “Failures in Communication including a failure to appropriately liaise with the deceased's Family and, specifically, [the deceased]'s mother to establish the suitability and safety of a discharge to her address not least in the context of [the deceased]'s disclosure that discharge to his mother's home might”

6. 6. inadequate discharge planning and execution

   “f) Failures in Discharge Planning and Execution: specifically, in addition to the features above, a failure to actively reconsider the safety of the discharge on the afternoon of the 17th October in light of the disclosure from [the deceased]'s mother that she would not, as had been previously indicated, be able to either collect [the deceased] from the Ward or be at her home when he was discharged. There was no evidence of how, in fact, [the deceased] even left the Unit. It is likely that the chaotic and unsupported nature”

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