David Phillips
16 Sept 2016 · Coroner Colin Phillips · Swansea Neath and Port Talbot
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. inadequate mental health assessment in police custody
“An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise.”
2. incomplete medication review due to missing medical records
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“The absence of a Medication Reconciliation Policy at the University Hospital of Wales over the relevant period made it much harder for the individual failures of the admitting doctor and initial pharmacist to be picked up.”
This report
“The Health Care Professional did not have access to detainee's medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred.”
Responses
No published response was found on judiciary.uk.