David Hughes
9 Feb 2016 · Coroner Catherine Mason · Leicestershire City and South Leicestershire
The coroner's concerns
1. inadequate observation frequency
“Level 2 observations were not conducted at the prescribed time intervals and periods of up to two hours lapsed between observations that should have been conducted every 15 minutes”
2. inaccurate fluid balance documentation
“Fluid balance charts were not properly completed”
3. absence of call bell system
“Patient bedrooms are not fitted with a call bell system”
4. potential lack of clinical awareness of physical deterioration
“The nursing staff who gave evidence were Registered Mental Health Nurses or Health Care Support Workers”
Responses
David-Hughes-Response.pdf ↗· Leicestershire Partnership NHS Trust
Stated action · 30 April 2016
“The Therapeutic Observation Policy will be reviewed by 30 April 2016 to consider how the completion of therapeutic observation for physical health concerns should be included or if separate guidance is required.”