Deidre Harvey
The coroner's concerns
1. lack of active input by outside consultants into mental health unit care
“patients on Mental Health Units often have significant physical problems which are treated by outside consultants, who may have little input into their care on the ward or may not even know they are there”
2. obvious ligature points not rectified promptly
“an obvious ligature point was identified in September 2016 in the Mental Health Unit, and yet bureaucratic processes meant that approval for funding the rectification of this ligature point was held up for months”
3. ineffective system to track items taken from and returned to patients
“no evidence of any effective system to identify wno had what item, and when”
4. confusion in risk management responsibilities
“there was confusion between staff on the Mental Health Unit and the Community Psychiatric Nurse over management of risk”
5. toxic buildup of hydroxychloroquine in lupus patients
“Hydroxychloroquine could build up to toxic levels even with normal dosage”
6. lack of routine clinical monitoring of hydroxychloroquine levels
“there is no routine checking of Hydroxychioroquine levels at clinical level”
Responses
2018-0266-Response-by-Department-of-Health-Social-Care.pdf ↗· Department of Health and Social Care
2018-0266-Response-by-MHRA.pdf ↗· Cwm Taf University Health Board
Stated action
“We have further considered your concerns that there may be other dependent persons suffering from lupus (or other conditions for which hydroxychloroquine is prescribed in NHS hospitals in England and Wales) who may also have toxic levels of hydroxychloroquine in their system unbeknown to their carers. Some”
2018-0266-Response-by-NHS-Improvement.pdf ↗· Royal College of Psychiatrists
Stated action
“We stand ready to support the MHRA in ensuring any future changes to monitoring reach all appropriate healthcare professionals and patients, including through our shared national network of Medication Safety Officers.”
2018-0266-Response-by-University-Health-Board.pdf ↗· Cwm Taf University Health Board
2018-0266-Response-by-Welsh-Government.pdf ↗· Welsh Government