Dominic White
24 May 2017 · Coroner ME Hassell · London Inner (North)
The coroner's concerns
1. lack of robust protocol to ensure all relevant personnel are aware of observation level
“following Mr [name redacted] death, the level of (mental health) observations of a patient at the Whittington Hospital Emergency Unit is now clearly documented”
2. lack of recognition of potential risk in allowing patient to leave hospital
“The C&I approved mental health professional (AMHP) who gave Mr [name redacted] permission to leave the hospital to go to McDonald's, after the decision had been made to detain him under section 2 of the Mental Health Act, acknowledged that she should have discussed this first with a colleague”
Responses
2017-0177-Response-by-Whittington-Hospital-NHS2-Trust.pdf ↗· Whittington Health NHS Trust
Stated action
“The mental health liaison team is responsible for informing the nurse in charge of Whittington Hospital's ED and the named nurse looking after the patient in the ED what the recommended level of observation is”
Stated action
“The nurse in charge of ED and the mental health liaison team are jointly responsible for ensuring that security staff and any other relevant Whittington ED staff are fully aware of the required observation level”
Stated action
“Visiting AHMPs and section 12 doctors must introduce themselves to the nurse in charge of ED and the named nurse responsible for the patient and request a clinical handover (Including the current observation level) and to view the mental health care plan”
Stated action
“Whittington Hospital's ED staff are responsible for ensuring that the patient is observed in line with the observation level as documented in the mental health care plan”
Stated action
“As part of improving communication between organisations signage has been introduced in Whittington ED, which is prominently placed around the nurses' station, to ensure that visiting doctors and AHMPs are aware of this process and that the name of the patient's allocated nurse and any 1:1 or 'special' staff member is visible outside the patient's cubicle”
Stated action
“To ensure that the level of observations is being complied with and that the clinical decision making regarding Mental Health patients is robust Senior Whittington ED staff members (nurse in charge, site team, ED registrar or consultant) conduct a situation report 5 times per day in which the status of the department including 2 length of stay of mental health patients and risk assessment is discussed, this is followed by a review in which plans for patients are confirmed and quality of care is”